Provider Demographics
NPI:1932500535
Name:CLEARY, KRISTEN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:
Last Name:CLEARY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 REBERRY LANE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259
Mailing Address - Country:US
Mailing Address - Phone:845-260-0571
Mailing Address - Fax:
Practice Address - Street 1:623 OAK ST
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-4313
Practice Address - Country:US
Practice Address - Phone:904-531-5152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW139281041C0700X
NY73-0795871041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Multi-Specialty