Basic Information
| Provider Information | |||||||||
| NPI: | 1881037471 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GITTENS | ||||||||
| FirstName: | KENRICK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A.,B.A.,A.A., | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GITTENS | ||||||||
| OtherFirstName: | KENRICK | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMHC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 175 FULTON AVE STE 500 | ||||||||
| Address2: | |||||||||
| City: | HEMPSTEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115503724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165052003 | ||||||||
| FaxNumber: | 5165052011 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 FULTON AVE STE 500 | ||||||||
| Address2: | |||||||||
| City: | HEMPSTEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115503724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165052003 | ||||||||
| FaxNumber: | 5165052011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2013 | ||||||||
| LastUpdateDate: | 04/12/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 002648 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.