Provider Demographics
NPI:1851675722
Name:DURIVAGE, KATHLEEN A (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:DURIVAGE
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 1:2025 ROUTE 9 W
Mailing Address - Street 2:
Mailing Address - City:RAVENA
Mailing Address - State:NY
Mailing Address - Zip Code:12143
Mailing Address - Country:US
Mailing Address - Phone:518-756-5200
Mailing Address - Fax:518-756-1988
Practice Address - Street 1:16 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-1217
Practice Address - Country:US
Practice Address - Phone:518-756-5200
Practice Address - Fax:518-756-1988
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR057-0571041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool