Provider Demographics
NPI:1306899190
Name:MERTZ, KATHLEEN (LCSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MERTZ
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 1:10300 SHORE FRONT PKWY
Mailing Address - Street 2:APT 5B
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-2788
Mailing Address - Country:US
Mailing Address - Phone:718-945-3785
Mailing Address - Fax:
Practice Address - Street 1:800 POLY PL
Practice Address - Street 2:122
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-7104
Practice Address - Country:US
Practice Address - Phone:718-836-6600
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR038765-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical