Provider Demographics
NPI:1699896092
Name:WILLGREN, KRISTER (LCSW-R)
Entity type:Individual
Prefix:
First Name:KRISTER
Middle Name:
Last Name:WILLGREN
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LADENTOWN RD
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-2728
Mailing Address - Country:US
Mailing Address - Phone:917-538-7075
Mailing Address - Fax:
Practice Address - Street 1:1 LADENTOWN RD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-2728
Practice Address - Country:US
Practice Address - Phone:917-538-7075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0773191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02962958Medicaid
NY02962958Medicaid