Provider Demographics
NPI:1366219081
Name:CARDER-GANGI, KRISTIN CARUSO (LCSW)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:CARUSO
Last Name:CARDER-GANGI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:KRISTIN
Other - Middle Name:CARUSO
Other - Last Name:CARDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:67 UNQUA RD
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-6728
Mailing Address - Country:US
Mailing Address - Phone:631-848-3975
Mailing Address - Fax:
Practice Address - Street 1:597 MIDDLE RD
Practice Address - Street 2:
Practice Address - City:BAYPORT
Practice Address - State:NY
Practice Address - Zip Code:11705-1925
Practice Address - Country:US
Practice Address - Phone:631-533-0708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0952931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty