Provider Demographics
NPI:1114331410
Name:CLAVIN-VUNKANNON, KATHRYN HAMMA (LMSW, LCSW, CASAC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:HAMMA
Last Name:CLAVIN-VUNKANNON
Suffix:
Gender:F
Credentials:LMSW, LCSW, CASAC
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:HAMMA
Other - Last Name:CLAVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24 WINDING PATH
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-2251
Mailing Address - Country:US
Mailing Address - Phone:631-905-9998
Mailing Address - Fax:
Practice Address - Street 1:24 WINDING PATH
Practice Address - Street 2:
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949-2251
Practice Address - Country:US
Practice Address - Phone:631-905-9998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY31376101YA0400X
NY085650104100000X
NY0858911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker