Provider Demographics
NPI:1013197086
Name:CONDIE, KRISTIN (LCSW-R)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:CONDIE
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 MCFADDEN RD
Mailing Address - Street 2:
Mailing Address - City:APALACHIN
Mailing Address - State:NY
Mailing Address - Zip Code:13732-3808
Mailing Address - Country:US
Mailing Address - Phone:607-761-7782
Mailing Address - Fax:
Practice Address - Street 1:289 MCFADDEN RD
Practice Address - Street 2:
Practice Address - City:APALACHIN
Practice Address - State:NY
Practice Address - Zip Code:13732-3808
Practice Address - Country:US
Practice Address - Phone:607-761-7782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-07
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY077541104100000X
NYR0847231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00618162OtherGROUP MEDICAID NUMBER