Provider Demographics
NPI:1053665638
Name:KLINGENSMITH SHIELDS, CAL (LCSW)
Entity Type:Individual
Prefix:
First Name:CAL
Middle Name:
Last Name:KLINGENSMITH SHIELDS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:LINDSAY SHIELDS
Other - Last Name:KLINGENSMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:142 E 27TH ST APT 1A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-9057
Mailing Address - Country:US
Mailing Address - Phone:929-259-2059
Mailing Address - Fax:
Practice Address - Street 1:142 E 27TH ST SUITE 1A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-9057
Practice Address - Country:US
Practice Address - Phone:929-259-2059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-03
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0836271041C0700X
NY086888104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03517411Medicaid