Basic Information
| Provider Information | |||||||||
| NPI: | 1770227373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AVILA CALDERON | ||||||||
| FirstName: | KISSY | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 902 DREW ST APT 423 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112085161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9174743831 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2604 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104541199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182920100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2022 | ||||||||
| LastUpdateDate: | 04/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 115926 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.