Provider Demographics
NPI:1215916473
Name:NOVAK, KIM (LCSW)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:
Last Name:NOVAK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:NOVAK HERRMANN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 298
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:CT
Mailing Address - Zip Code:06424-0298
Mailing Address - Country:US
Mailing Address - Phone:860-365-5249
Mailing Address - Fax:860-365-5249
Practice Address - Street 1:26 LAKEVIEW ST
Practice Address - Street 2:
Practice Address - City:EAST HAMPTON
Practice Address - State:CT
Practice Address - Zip Code:06424-1200
Practice Address - Country:US
Practice Address - Phone:860-365-5249
Practice Address - Fax:860-365-5249
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-15
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0051111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004239548-00Medicaid
VA486904OtherVALUE OPTIONS
KY309362Medicare UPIN
KY0001114588Medicare UPIN
CTP3083096Medicare UPIN
KY709302000Medicare UPIN
VA486904OtherVALUE OPTIONS