Provider Demographics
NPI:1316241169
Name:EDDY, KRISTEN M (LMSW)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:EDDY
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 1:257 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-2522
Mailing Address - Country:US
Mailing Address - Phone:607-729-6206
Mailing Address - Fax:607-729-1858
Practice Address - Street 1:80 WILLIAM DONNELLY INDUS PKWY
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:NY
Practice Address - Zip Code:14892-1500
Practice Address - Country:US
Practice Address - Phone:607-565-9594
Practice Address - Fax:607-565-7194
Is Sole Proprietor?:No
Enumeration Date:2011-01-07
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0805451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00618162OtherGROUP PRACTICE MEDICAID NUMBER
39062AOtherGROUP PRACTICE MEDICARE NUMBER