Provider Demographics
NPI:1275668923
Name:KINIGSTEIN, LAURIE DYAN (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:DYAN
Last Name:KINIGSTEIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:DYAN
Other - Last Name:MOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1710 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-4836
Mailing Address - Country:US
Mailing Address - Phone:310-633-1414
Mailing Address - Fax:
Practice Address - Street 1:12304 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 215
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2551
Practice Address - Country:US
Practice Address - Phone:310-625-3305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 212821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASW21282Medicare ID - Type Unspecified