Provider Demographics
NPI:1780763409
Name:BARRACK, BRUCE (LCSW)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:BARRACK
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 1:239 GOLDEN HILL LN
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-6441
Mailing Address - Country:US
Mailing Address - Phone:845-486-2703
Mailing Address - Fax:
Practice Address - Street 1:239 GOLDEN HILL LN
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401
Practice Address - Country:US
Practice Address - Phone:845-340-4023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0275861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02538329Medicaid