Provider Demographics
NPI:1114281052
Name:MCCARTHY, KIM ILENE
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:ILENE
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:10965-2249
Mailing Address - Country:US
Mailing Address - Phone:845-721-9227
Mailing Address - Fax:
Practice Address - Street 1:155 W PARK AVE
Practice Address - Street 2:
Practice Address - City:PEARL RIVER
Practice Address - State:NY
Practice Address - Zip Code:10965-2249
Practice Address - Country:US
Practice Address - Phone:845-721-9227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist