Provider Demographics
NPI:1164006060
Name:FIBKINS, KAITLIN (LMSW)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:FIBKINS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:EAST MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11940-1539
Mailing Address - Country:US
Mailing Address - Phone:631-875-6224
Mailing Address - Fax:
Practice Address - Street 1:901 E MAIN ST STE 508
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2680
Practice Address - Country:US
Practice Address - Phone:631-727-6220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11210101104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11210101OtherNEW YORK STATE