Provider Demographics
NPI:1528500337
Name:EASTERN DOOR LICENSED CLINICAL SOCIAL WORK, PC
Entity type:Organization
Organization Name:EASTERN DOOR LICENSED CLINICAL SOCIAL WORK, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLYANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUGENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, PHD
Authorized Official - Phone:518-252-7073
Mailing Address - Street 1:620 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:NY
Mailing Address - Zip Code:12144-1300
Mailing Address - Country:US
Mailing Address - Phone:518-252-7073
Mailing Address - Fax:518-252-7073
Practice Address - Street 1:620 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:NY
Practice Address - Zip Code:12144-1300
Practice Address - Country:US
Practice Address - Phone:518-252-7073
Practice Address - Fax:518-252-7073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-10
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03068682Medicaid