Basic Information
| Provider Information | |||||||||
| NPI: | 1295028165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FITZJEFFERIES | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, LCAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 N CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271012939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367484025 | ||||||||
| FaxNumber: | 3367484108 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 N CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271012939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367484025 | ||||||||
| FaxNumber: | 3367484108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2011 | ||||||||
| LastUpdateDate: | 02/03/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C006860 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | 1967 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 6007832 | 05 | NC | MEDICAID |