=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811761273
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH MICHEAL TROELLER LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2023
-----------------------------------------------------
Last Update Date | 12/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40 PENNY LN APT 11
-----------------------------------------------------
City | HAMPTON BAYS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11946-3200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 163-190-2188
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 PENNY LN APT 11
-----------------------------------------------------
City | HAMPTON BAYS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11946-3200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-902-1883
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 121640-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------