Provider Demographics
NPI:1053502518
Name:KERI MICA LCSW PC
Entity Type:Organization
Organization Name:KERI MICA LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KERI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MICA-SUTTMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:516-410-7138
Mailing Address - Street 1:111 HART STREET
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-1760
Mailing Address - Country:US
Mailing Address - Phone:516-410-7138
Mailing Address - Fax:516-679-0736
Practice Address - Street 1:176 N VILLAGE AVE
Practice Address - Street 2:SUITE 2E
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3800
Practice Address - Country:US
Practice Address - Phone:516-410-7138
Practice Address - Fax:516-679-0736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02735202Medicaid
NYQ62025Medicare UPIN
NY02735202Medicaid