Provider Demographics
NPI:1578633723
Name:KENN, RITA (LCSW)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:
Last Name:KENN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:RITA
Other - Middle Name:
Other - Last Name:MIRANDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:179 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-1406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:270 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1224
Practice Address - Country:US
Practice Address - Phone:516-239-1945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNT5951Medicare ID - Type Unspecified