Provider Demographics
NPI:1336355395
Name:SERGIACOMI, KENNETH ROBERT (LMSW)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ROBERT
Last Name:SERGIACOMI
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 HALLOCK AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1214
Mailing Address - Country:US
Mailing Address - Phone:631-384-0624
Mailing Address - Fax:
Practice Address - Street 1:1050 HALLOCK AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1214
Practice Address - Country:US
Practice Address - Phone:631-384-0624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0735881-1104100000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor