Provider Demographics
NPI:1982796793
Name:EDWARDS, KENNETH (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MONTAUK HWY STE M
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4419
Mailing Address - Country:US
Mailing Address - Phone:631-766-6014
Mailing Address - Fax:
Practice Address - Street 1:500 MONTAUK HWY STE M
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4419
Practice Address - Country:US
Practice Address - Phone:631-766-6014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO36605-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN61651Medicare ID - Type Unspecified