1770894511 NPI number — MR. KEVIN MICHAEL LYCKE MSW/LCSW

Table of content: MR. KEVIN MICHAEL LYCKE MSW/LCSW (NPI 1770894511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770894511 NPI number — MR. KEVIN MICHAEL LYCKE MSW/LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LYCKE
Provider First Name:
KEVIN
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSW/LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770894511
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38 RICHMOND BLVD. 4A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RONKONKOMA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11779-3615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-334-0234
Provider Business Mailing Address Fax Number:
631-981-2679

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33 WALT WHITMAN RD
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
HUNTINGTON STATION
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11746-3640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-334-0234
Provider Business Practice Location Address Fax Number:
631-981-2679
Provider Enumeration Date:
06/26/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  PR065283-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 03279229 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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