Basic Information
| Provider Information | |||||||||
| NPI: | 1770113359 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEO | ||||||||
| FirstName: | KAITLYN | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18 RICHLEE ST | ||||||||
| Address2: | |||||||||
| City: | BLUE POINT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117151517 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 90 ADAMS AVE | ||||||||
| Address2: | |||||||||
| City: | HAUPPAUGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117883631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9342236500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2020 | ||||||||
| LastUpdateDate: | 01/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 108309-01 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.