Provider Demographics
NPI:1063502425
Name:REDDAN, KENNETH (LCSW)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:REDDAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7304 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-2604
Mailing Address - Country:US
Mailing Address - Phone:718-871-4593
Mailing Address - Fax:718-871-4593
Practice Address - Street 1:20 GIORDAN CT
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303-2538
Practice Address - Country:US
Practice Address - Phone:718-871-4593
Practice Address - Fax:718-228-3905
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY071025-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNG8481Medicare PIN
NY02070400Medicare ID - Type Unspecified