Provider Demographics
NPI:1922725308
Name:URDAHL, KRISTIE MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIE
Middle Name:MARIE
Last Name:URDAHL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:KRISTIE
Other - Middle Name:MARIE
Other - Last Name:RUGOLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:7 MARC ST
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4314
Mailing Address - Country:US
Mailing Address - Phone:631-289-2200
Mailing Address - Fax:
Practice Address - Street 1:201 SUNRISE HWY W
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1868
Practice Address - Country:US
Practice Address - Phone:631-289-2200
Practice Address - Fax:631-286-6955
Is Sole Proprietor?:No
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0840141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY084014OtherLCSW LICENSE NUMBER