Provider Demographics
NPI:1184701716
Name:SHEA, KATHLEEN R (LCSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:R
Last Name:SHEA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99213
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0213
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-7347
Practice Address - Street 1:1516 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-1480
Practice Address - Fax:682-885-3600
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX124001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX108175403Medicaid
TX124048OtherSUPERIOR PIN
TX87130QOtherBCBSTX IND PIN
1336198894OtherGRP NPI NUMBER
TX00G981OtherBCBSTX GRP PIN
TX1919614OtherFIRSTHEALTH PIN
TX10013524OtherAMERIGROUP PIN