Provider Demographics
NPI:1447834221
Name:CARTER, KATHLEEN GANNON (MSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:GANNON
Last Name:CARTER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 BROOKES AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2799
Mailing Address - Country:US
Mailing Address - Phone:301-318-1133
Mailing Address - Fax:
Practice Address - Street 1:8 BROOKES AVE STE 200
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2799
Practice Address - Country:US
Practice Address - Phone:301-318-1133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-08
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23352104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD83-1246815Medicaid