Provider Demographics
NPI:1831203025
Name:DEBRUIN, KATHRYN A (LCSW-R)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
Last Name:DEBRUIN
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:PENDERGAST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:132 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-1304
Mailing Address - Country:US
Mailing Address - Phone:585-742-3804
Mailing Address - Fax:
Practice Address - Street 1:3019 COUNTY COMPLEX DR
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-9505
Practice Address - Country:US
Practice Address - Phone:585-396-4363
Practice Address - Fax:585-396-4993
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0451211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY103283EUOtherPREFERRED CARE
NY07300045121Medicaid
NYEMOtherEXCELLUS
NY3109089OtherVALUE OPTIONS
NY07300045121Medicaid