Provider Demographics
NPI:1023271566
Name:BRAGG, KEVIN SCOTT (LCSW CASAC)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:SCOTT
Last Name:BRAGG
Suffix:
Gender:M
Credentials:LCSW CASAC
Other - Prefix:MR
Other - First Name:KEVIN
Other - Middle Name:SCOTT
Other - Last Name:BRAGG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW CASAC
Mailing Address - Street 1:237 PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-2116
Mailing Address - Country:US
Mailing Address - Phone:516-356-1954
Mailing Address - Fax:516-798-2939
Practice Address - Street 1:237 PACIFIC ST
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-2116
Practice Address - Country:US
Practice Address - Phone:516-356-1954
Practice Address - Fax:516-798-2939
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR043029-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical