Basic Information
| Provider Information | |||||||||
| NPI: | 1568920361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUMMINGS | ||||||||
| FirstName: | KRISTEN | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38 HOMESTEAD LN | ||||||||
| Address2: | |||||||||
| City: | OTISVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109632106 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 17 SUSSEX ST | ||||||||
| Address2: | |||||||||
| City: | PORT JERVIS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 127712430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8458566344 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2019 | ||||||||
| LastUpdateDate: | 03/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 104457 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 104457 | 01 | NY | LMSW | OTHER |