Provider Demographics
NPI:1063940807
Name:ERICKSON-JORGE, KELLY LINDA (LMSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LINDA
Last Name:ERICKSON-JORGE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 W 35TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-2505
Mailing Address - Country:US
Mailing Address - Phone:718-681-8700
Mailing Address - Fax:646-380-1322
Practice Address - Street 1:459 E 149TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-1314
Practice Address - Country:US
Practice Address - Phone:855-681-8700
Practice Address - Fax:646-380-1322
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY079786104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker