Provider Demographics
NPI:1356661037
Name:GAGNIDZE-MCCORMICK, KETEVAN (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:KETEVAN
Middle Name:
Last Name:GAGNIDZE-MCCORMICK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-6602
Mailing Address - Country:US
Mailing Address - Phone:845-561-7284
Mailing Address - Fax:
Practice Address - Street 1:10 BRUCE ST
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-6602
Practice Address - Country:US
Practice Address - Phone:845-561-7284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003123101YM0800X
NJ37PC00314800101YP2500X
NJ44SW05190800104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker