Healthcare Provider Details

I. General information

NPI: 1003646589
Provider Name (Legal Business Name): KELSEY DERAFFELE CIVETTA MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 KENT AVE APT 308
BROOKLYN NY
11249-4895
US

IV. Provider business mailing address

175 KENT AVE APT 308
BROOKLYN NY
11249-4895
US

V. Phone/Fax

Practice location:
  • Phone: 914-262-1251
  • Fax:
Mailing address:
  • Phone: 914-262-1251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: