Provider Demographics
NPI:1578034336
Name:KENZIK, KELLE M (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLE
Middle Name:M
Last Name:KENZIK
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 1:2009 BODANYI PL
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-6531
Mailing Address - Country:US
Mailing Address - Phone:631-621-8485
Mailing Address - Fax:
Practice Address - Street 1:2009 BODANYI PL
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-6531
Practice Address - Country:US
Practice Address - Phone:631-621-8485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2021-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0893751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical