Provider Demographics
NPI:1790153971
Name:ROYSTER, KIRK (LMSW)
Entity Type:Individual
Prefix:MR
First Name:KIRK
Middle Name:
Last Name:ROYSTER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:566 JEFFERSON AVE
Mailing Address - Street 2:APT. 1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-1607
Mailing Address - Country:US
Mailing Address - Phone:646-258-7936
Mailing Address - Fax:
Practice Address - Street 1:566 JEFFERSON AVE
Practice Address - Street 2:APT. 1
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-1607
Practice Address - Country:US
Practice Address - Phone:646-258-7936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093615-1101Y00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor