Provider Demographics
NPI:1013457506
Name:O'DONOGHUE, KEVIN (CSW)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:O'DONOGHUE
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 W 57TH ST
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-2303
Mailing Address - Country:US
Mailing Address - Phone:212-757-4488
Mailing Address - Fax:212-757-3555
Practice Address - Street 1:119 W 57TH ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-2303
Practice Address - Country:US
Practice Address - Phone:212-757-4488
Practice Address - Fax:212-757-3555
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYS0074841101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNYS0074841OtherLICENSE