Provider Demographics
NPI:1205391018
Name:KENSHO PSYCHOTHERAPY, LCSW, PLLC
Entity Type:Organization
Organization Name:KENSHO PSYCHOTHERAPY, LCSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FLUDD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:718-208-3914
Mailing Address - Street 1:14410 256TH ST
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-2543
Mailing Address - Country:US
Mailing Address - Phone:718-208-3914
Mailing Address - Fax:
Practice Address - Street 1:381 SUNRISE HWY STE 602
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-3006
Practice Address - Country:US
Practice Address - Phone:347-868-7813
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-06
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1184822587Medicaid
NY938144OtherBEACON