Basic Information
| Provider Information | |||||||||
| NPI: | 1417105636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COTTLE | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | AUSTIN | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 BRADY RD | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109903846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8459869439 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16-24 UNION STREET | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453435556 | ||||||||
| FaxNumber: | 8453433341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2008 | ||||||||
| LastUpdateDate: | 12/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 083530 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.