Provider Demographics
NPI:1124182027
Name:KANE, MICHELLE (LCSW, BCD)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:KANE
Suffix:
Gender:F
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 FAIRBANKS BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-2619
Mailing Address - Country:US
Mailing Address - Phone:516-367-1087
Mailing Address - Fax:516-367-1782
Practice Address - Street 1:26 FAIRBANKS BLVD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2619
Practice Address - Country:US
Practice Address - Phone:516-367-1087
Practice Address - Fax:516-367-1782
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR021079-11041C0700X
NJ44SC013322001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN74161Medicare ID - Type Unspecified