Provider Demographics
NPI:1497118350
Name:KENNETH FLIESSER LCSW PC
Entity Type:Organization
Organization Name:KENNETH FLIESSER LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:FLIESSER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:845-709-8938
Mailing Address - Street 1:104 BELLOWS LN
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-2439
Mailing Address - Country:US
Mailing Address - Phone:845-709-8938
Mailing Address - Fax:845-678-1889
Practice Address - Street 1:978 ROUTE 45
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-3521
Practice Address - Country:US
Practice Address - Phone:845-709-8938
Practice Address - Fax:845-678-1889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY076582261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA30072727Medicare UPIN