Basic Information
| Provider Information | |||||||||
| NPI: | 1013524784 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IACOMINI | ||||||||
| FirstName: | KAITLIN | ||||||||
| MiddleName: | MARIA | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 464 CREEK RD | ||||||||
| Address2: | |||||||||
| City: | PLEASANT VALLEY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125697157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454891447 | ||||||||
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| Practice Location | |||||||||
| Address1: | 26 OAKLEY ST | ||||||||
| Address2: | |||||||||
| City: | POUGHKEEPSIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 126012005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887502266 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2020 | ||||||||
| LastUpdateDate: | 09/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | P106987 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.