Provider Demographics
NPI:1811761273
Name:TROELLER, KENNETH MICHEAL (LMSW)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHEAL
Last Name:TROELLER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 PENNY LN APT 11
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-3200
Mailing Address - Country:US
Mailing Address - Phone:631-902-1883
Mailing Address - Fax:
Practice Address - Street 1:40 PENNY LN APT 11
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-3200
Practice Address - Country:US
Practice Address - Phone:163-190-2188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2023-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121640-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker