Healthcare Provider Details

I. General information

NPI: 1982771960
Provider Name (Legal Business Name): KIM MARIE AQUINO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 09/03/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10475 5TH ARMOURED DIVISION DR
FT DRUM NY
13602
US

IV. Provider business mailing address

10475 5TH ARMOURED DIVISION DR
FT DRUM NY
13602
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-2557
  • Fax:
Mailing address:
  • Phone: 315-772-2557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904008697
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: