Healthcare Provider Details

I. General information

NPI: 1174694996
Provider Name (Legal Business Name): KATHLEEN LYSOHIR LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9729 64TH RD
REGO PARK NY
11374-2240
US

IV. Provider business mailing address

9729 64TH RD
REGO PARK NY
11374-2240
US

V. Phone/Fax

Practice location:
  • Phone: 718-896-3400
  • Fax:
Mailing address:
  • Phone: 718-896-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number038843
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: