Provider Demographics
NPI:1558511683
Name:MIGUEL, KRISTEN DIANE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:DIANE
Last Name:MIGUEL
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 1:635 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2226
Mailing Address - Country:US
Mailing Address - Phone:315-671-2952
Mailing Address - Fax:315-671-2943
Practice Address - Street 1:635 JAMES ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2226
Practice Address - Country:US
Practice Address - Phone:315-671-2952
Practice Address - Fax:315-671-2943
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0796991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01649605Medicaid