Provider Demographics
NPI:1548579253
Name:KICZUK, KRISTIN ELIZABETH (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:ELIZABETH
Last Name:KICZUK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:KRISTIN
Other - Middle Name:ELIZABETH
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:255 HEMPSTEAD ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-6204
Mailing Address - Country:US
Mailing Address - Phone:860-443-2896
Mailing Address - Fax:860-442-5909
Practice Address - Street 1:255 HEMPSTEAD ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-6204
Practice Address - Country:US
Practice Address - Phone:860-443-2896
Practice Address - Fax:860-442-5909
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT92381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical