Healthcare Provider Details

I. General information

NPI: 1942527072
Provider Name (Legal Business Name): KIM MARIE TESSIN I LCSWR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 04/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 BROADWAY SUITE 200
NEWBURGH NY
12550-5408
US

IV. Provider business mailing address

159 MAIN ST
CORNWALL NY
12518-1509
US

V. Phone/Fax

Practice location:
  • Phone: 845-562-7326
  • Fax: 845-565-0826
Mailing address:
  • Phone: 845-458-5016
  • Fax: 845-565-0826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR054076-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: