Provider Demographics
NPI:1568547628
Name:CORKHILL-LAULETTA, KELLY ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:CORKHILL-LAULETTA
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 1:457 HEATHCOTE RD
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-1819
Mailing Address - Country:US
Mailing Address - Phone:631-225-0546
Mailing Address - Fax:718-539-9314
Practice Address - Street 1:457 HEATHCOTE RD
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-1819
Practice Address - Country:US
Practice Address - Phone:631-225-0546
Practice Address - Fax:718-539-9314
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY73 0707451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11546573OtherCAQH PROVIDER NUMBER