Provider Demographics
NPI:1790946242
Name:HUNTER-EPPS, KLYDE STUCKEY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KLYDE
Middle Name:STUCKEY
Last Name:HUNTER-EPPS
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 1:1855 UNION BOULEVARD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BAYSHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11726
Mailing Address - Country:US
Mailing Address - Phone:631-665-0229
Mailing Address - Fax:631-665-0442
Practice Address - Street 1:1855 UNION BOULEVARD
Practice Address - Street 2:SUITE A
Practice Address - City:BAYSHORE
Practice Address - State:NY
Practice Address - Zip Code:11726
Practice Address - Country:US
Practice Address - Phone:631-665-0229
Practice Address - Fax:631-665-0442
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR010919SOCIALWORKER104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
11453835OtherCAQH
NYN8A811Medicare UPIN