Provider Demographics
NPI:1073252912
Name:KICINSKI, LISA MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:KICINSKI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 S MAIN ST STE 28AND32
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3111
Mailing Address - Country:US
Mailing Address - Phone:806-348-5614
Mailing Address - Fax:
Practice Address - Street 1:114 S MAIN ST STE 28AND32
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-3111
Practice Address - Country:US
Practice Address - Phone:860-348-5614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT146841041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical