Provider Demographics
NPI:1124614995
Name:MCCLINTOCK, KAITLYN (LMSW)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:MCCLINTOCK
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 1:3600 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-4116
Mailing Address - Country:US
Mailing Address - Phone:631-920-8630
Mailing Address - Fax:
Practice Address - Street 1:3600 ROUTE 112
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-4116
Practice Address - Country:US
Practice Address - Phone:631-920-8630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111077-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker