Provider Demographics
NPI:1790816049
Name:KINSELLA, STEPHEN R (LCSW)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:KINSELLA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-3840
Mailing Address - Country:US
Mailing Address - Phone:914-450-6007
Mailing Address - Fax:
Practice Address - Street 1:51 SHERMAN HILL RD STE 203
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:CT
Practice Address - Zip Code:06798-3648
Practice Address - Country:US
Practice Address - Phone:203-681-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0063671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11163OtherCASAC
NY73075100OtherLCSW