Healthcare Provider Details

I. General information

NPI: 1194045260
Provider Name (Legal Business Name): KEITH KOBLICK LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 POLY PL APT. 10J
BROOKLYN NY
11209-7104
US

IV. Provider business mailing address

800 POLY PL APT. 10J
BROOKLYN NY
11209-7104
US

V. Phone/Fax

Practice location:
  • Phone: 171-883-6660
  • Fax:
Mailing address:
  • Phone: 171-883-6660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number087475
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: