Provider Demographics
NPI:1184809022
Name:STANDFAST, KIMBERLY (LCSW)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:STANDFAST
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 1:193 N COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2104
Mailing Address - Country:US
Mailing Address - Phone:631-805-7304
Mailing Address - Fax:
Practice Address - Street 1:6120 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3557
Practice Address - Country:US
Practice Address - Phone:718-779-1234
Practice Address - Fax:718-779-7775
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0896641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical