Provider Demographics
NPI:1316631849
Name:VISALLI, KRISTIN LYNN (LMSW)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LYNN
Last Name:VISALLI
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 1:61 DELANO ST
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142-1400
Mailing Address - Country:US
Mailing Address - Phone:315-298-6564
Mailing Address - Fax:315-298-7831
Practice Address - Street 1:640 COUNTY ROUTE 22
Practice Address - Street 2:
Practice Address - City:PARISH
Practice Address - State:NY
Practice Address - Zip Code:13131-3339
Practice Address - Country:US
Practice Address - Phone:315-625-5210
Practice Address - Fax:315-625-7974
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114434104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty