Provider Demographics
NPI:1376201525
Name:KIERNAN, CAROLINE MARIE
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:MARIE
Last Name:KIERNAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 WAGNER DR
Mailing Address - Street 2:
Mailing Address - City:PAWLING
Mailing Address - State:NY
Mailing Address - Zip Code:12564-1730
Mailing Address - Country:US
Mailing Address - Phone:845-516-7248
Mailing Address - Fax:
Practice Address - Street 1:30 WAGNER DR
Practice Address - Street 2:
Practice Address - City:PAWLING
Practice Address - State:NY
Practice Address - Zip Code:12564-1730
Practice Address - Country:US
Practice Address - Phone:845-516-7248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-06
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1376201525Medicaid