Provider Demographics
NPI:1871601666
Name:KISSICK, RONALD L (LCSW)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:L
Last Name:KISSICK
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 1:3220 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:ENDWELL
Mailing Address - State:NY
Mailing Address - Zip Code:13760-5758
Mailing Address - Country:US
Mailing Address - Phone:607-754-4520
Mailing Address - Fax:607-754-4021
Practice Address - Street 1:3220 PEARL ST
Practice Address - Street 2:
Practice Address - City:ENDWELL
Practice Address - State:NY
Practice Address - Zip Code:13760-5758
Practice Address - Country:US
Practice Address - Phone:607-754-4520
Practice Address - Fax:607-754-4021
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPRO154731-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG0184797040OtherEXCELLUS ROCHESTER
NY1237792OtherAETNA
NY1237792OtherAETNA