Provider Demographics
NPI:1902172984
Name:LEBENS, CORNELIA S (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CORNELIA
Middle Name:S
Last Name:LEBENS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:KITTY
Other - Middle Name:
Other - Last Name:LEBENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:4 PARK ST
Mailing Address - Street 2:P.O. BOX 2086
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-2258
Mailing Address - Country:US
Mailing Address - Phone:516-457-2805
Mailing Address - Fax:
Practice Address - Street 1:350 MARTHA AVE
Practice Address - Street 2:
Practice Address - City:BELLPORT
Practice Address - State:NY
Practice Address - Zip Code:11713-1525
Practice Address - Country:US
Practice Address - Phone:631-286-6927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-24
Last Update Date:2012-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0368681041C0700X
NY1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR036868OtherCLINICAL SOCIAL WORK LICENSE