Provider Demographics
NPI:1427196922
Name:CHURCH, KATHLEEN ELLEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ELLEN
Last Name:CHURCH
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 1:406 E 80TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-1004
Mailing Address - Country:US
Mailing Address - Phone:917-312-3303
Mailing Address - Fax:
Practice Address - Street 1:406 E 80TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-1004
Practice Address - Country:US
Practice Address - Phone:917-312-3303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR 070378-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNV4041Medicare ID - Type UnspecifiedPROVIDER NUMBER