Provider Demographics
NPI:1275240137
Name:FACCIOLI LICARI, KRISTEN AMY (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:AMY
Last Name:FACCIOLI LICARI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:498 WESTERN HWY
Mailing Address - Street 2:
Mailing Address - City:BLAUVELT
Mailing Address - State:NY
Mailing Address - Zip Code:10913-2000
Mailing Address - Country:US
Mailing Address - Phone:845-359-3400
Mailing Address - Fax:845-359-5286
Practice Address - Street 1:498 WESTERN HWY
Practice Address - Street 2:
Practice Address - City:BLAUVELT
Practice Address - State:NY
Practice Address - Zip Code:10913-2000
Practice Address - Country:US
Practice Address - Phone:845-359-3400
Practice Address - Fax:845-359-5286
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0686241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical