Healthcare Provider Details

I. General information

NPI: 1184115388
Provider Name (Legal Business Name): KJG LCSW, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1844 E 12TH ST
BROOKLYN NY
11229-2702
US

IV. Provider business mailing address

1844 E 12TH ST
BROOKLYN NY
11229-2702
US

V. Phone/Fax

Practice location:
  • Phone: 917-618-2379
  • Fax:
Mailing address:
  • Phone: 917-618-2379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number73079357
License Number StateNY

VIII. Authorized Official

Name: MICHELLE YETTA CORDERO
Title or Position: PRESIDENT
Credential: LCSW-R
Phone: 917-618-2379