=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902504798
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AD KAVALIN LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2023
-----------------------------------------------------
Last Update Date | 11/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1618 JEFFERSON AVE APT 2E
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11385-4709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-577-7685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 850 7TH AVE STE 1106
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10019-0029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-577-7685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 120152
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------