Provider Demographics
NPI:1336558691
Name:WILCZEWSKI, KAITLIN
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:WILCZEWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 E 71ST ST
Mailing Address - Street 2:26
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4822
Mailing Address - Country:US
Mailing Address - Phone:860-918-6266
Mailing Address - Fax:
Practice Address - Street 1:416 E 71ST ST
Practice Address - Street 2:26
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4822
Practice Address - Country:US
Practice Address - Phone:860-918-6266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY092488104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker