Healthcare Provider Details

I. General information

NPI: 1154465599
Provider Name (Legal Business Name): MARTIN J. KNOWLES LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HURLEY AVE STE 4
KINGSTON NY
12401-2836
US

IV. Provider business mailing address

15 SHALE DR
BEARSVILLE NY
12409-5713
US

V. Phone/Fax

Practice location:
  • Phone: 845-430-3131
  • Fax:
Mailing address:
  • Phone: 845-616-1512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number051030
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: