Healthcare Provider Details

I. General information

NPI: 1881794907
Provider Name (Legal Business Name): KATHLEEN BRONNER FIKS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10848 70TH RD
FOREST HILLS NY
11375-3961
US

IV. Provider business mailing address

83 GLENWOOD RD
TENAFLY NJ
07670-1135
US

V. Phone/Fax

Practice location:
  • Phone: 718-261-3696
  • Fax: 201-568-4494
Mailing address:
  • Phone: 201-569-1819
  • Fax: 201-568-4494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR006078
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC00090300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: