Provider Demographics
NPI:1770894511
Name:LYCKE, KEVIN MICHAEL (MSW/LCSW)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:LYCKE
Suffix:
Gender:M
Credentials:MSW/LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 RICHMOND BLVD. 4A
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-3615
Mailing Address - Country:US
Mailing Address - Phone:631-334-0234
Mailing Address - Fax:631-981-2679
Practice Address - Street 1:33 WALT WHITMAN RD
Practice Address - Street 2:SUITE 106
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-3640
Practice Address - Country:US
Practice Address - Phone:631-334-0234
Practice Address - Fax:631-981-2679
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-26
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR065283-11041C0700X
NY0652831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03279229Medicaid
NY03279229Medicaid