Provider Demographics
NPI:1114410701
Name:KIMBERLY A. HOSTIG LICENSED CLINICAL SOCIAL WORKER PLLC
Entity Type:Organization
Organization Name:KIMBERLY A. HOSTIG LICENSED CLINICAL SOCIAL WORKER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOSTIG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:518-222-6752
Mailing Address - Street 1:22 HAMPTON CIR
Mailing Address - Street 2:
Mailing Address - City:MECHANICVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12118-3436
Mailing Address - Country:US
Mailing Address - Phone:518-423-6831
Mailing Address - Fax:
Practice Address - Street 1:8 STANLEY CIR STE 11
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110
Practice Address - Country:US
Practice Address - Phone:518-222-6752
Practice Address - Fax:518-786-0917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-08
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR075574-1261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)