Provider Demographics
NPI:1881037471
Name:GITTENS, KENRICK (MA,BA,AA,)
Entity type:Individual
Prefix:MR
First Name:KENRICK
Middle Name:
Last Name:GITTENS
Suffix:
Gender:M
Credentials:MA,BA,AA,
Other - Prefix:MR
Other - First Name:KENRICK
Other - Middle Name:
Other - Last Name:GITTENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:175 FULTON AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-3724
Mailing Address - Country:US
Mailing Address - Phone:516-505-2003
Mailing Address - Fax:516-505-2011
Practice Address - Street 1:175 FULTON AVE STE 500
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-3724
Practice Address - Country:US
Practice Address - Phone:516-505-2003
Practice Address - Fax:516-505-2011
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002648101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health