Provider Demographics
NPI:1265716591
Name:KILGORE, MATHEW DAVID (LCSW)
Entity type:Individual
Prefix:MR
First Name:MATHEW
Middle Name:DAVID
Last Name:KILGORE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 SUGARMILLS CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-8761
Mailing Address - Country:US
Mailing Address - Phone:585-694-0075
Mailing Address - Fax:
Practice Address - Street 1:33 SUGARMILLS CIR
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-8761
Practice Address - Country:US
Practice Address - Phone:585-694-0075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR-04416311041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical