Provider Demographics
NPI:1720338411
Name:BRISPORT, KEMYLEE SILAGAN (LMSW)
Entity Type:Individual
Prefix:
First Name:KEMYLEE
Middle Name:SILAGAN
Last Name:BRISPORT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3418 ELY AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-2636
Mailing Address - Country:US
Mailing Address - Phone:646-820-4612
Mailing Address - Fax:
Practice Address - Street 1:710 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2278
Practice Address - Country:US
Practice Address - Phone:646-820-4612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY114487104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program