Provider Demographics
NPI:1639626419
Name:KOLKER, STACIE LEE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:LEE
Last Name:KOLKER
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 1:61 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1058
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 BRUCE LN S
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-4508
Practice Address - Country:US
Practice Address - Phone:631-365-3031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096104104100000X
NY0900951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker