Provider Demographics
NPI:1437615374
Name:BLOODWORTH, KEMBA (LMSW)
Entity Type:Individual
Prefix:
First Name:KEMBA
Middle Name:
Last Name:BLOODWORTH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 MADISON ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-1647
Mailing Address - Country:US
Mailing Address - Phone:917-627-0308
Mailing Address - Fax:
Practice Address - Street 1:250 W 57TH ST FRNT 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10107-0005
Practice Address - Country:US
Practice Address - Phone:212-582-1566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
102L00000X
NY11233401104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11111111Medicaid