Provider Demographics
NPI:1689617490
Name:MICA-SUTTMILLER, KERI (LCSW)
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:
Last Name:MICA-SUTTMILLER
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 1:111 HART ST
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-1760
Mailing Address - Country:US
Mailing Address - Phone:516-410-7138
Mailing Address - Fax:516-679-0736
Practice Address - Street 1:176 N VILLAGE AVE
Practice Address - Street 2:SUITE 2E
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3800
Practice Address - Country:US
Practice Address - Phone:516-410-7138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0713161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN38T61Medicare ID - Type Unspecified