Provider Demographics
NPI:1124394507
Name:KUNKEL, HEATHER L (LCSW)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:KUNKEL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:28 W GRETNA RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:12569-6968
Mailing Address - Country:US
Mailing Address - Phone:203-491-8657
Mailing Address - Fax:
Practice Address - Street 1:28 W GRETNA RD
Practice Address - Street 2:
Practice Address - City:PLEASANT VALLEY
Practice Address - State:NY
Practice Address - Zip Code:12569-6968
Practice Address - Country:US
Practice Address - Phone:203-491-8657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2021-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0904681041C0700X
CT0103801041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008084354Medicaid