Healthcare Provider Details

I. General information

NPI: 1770227373
Provider Name (Legal Business Name): KISSY AVILA CALDERON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2604 3RD AVE
BRONX NY
10454-1199
US

IV. Provider business mailing address

8757 150TH ST APT 202
JAMAICA NY
11435-3589
US

V. Phone/Fax

Practice location:
  • Phone: 718-292-0100
  • Fax:
Mailing address:
  • Phone: 917-474-3831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number104041
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: