1225174907 NPI number — CARRIE SWIDERSKI PSYD

Table of content: CARRIE SWIDERSKI PSYD (NPI 1225174907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225174907 NPI number — CARRIE SWIDERSKI PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SWIDERSKI
Provider First Name:
CARRIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225174907
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
66 COLONIAL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERTOWN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06795-3106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-417-9110
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1002 GEORGIA ST UNIT 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTINGTON BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92648-4364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-417-9110
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/29/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 003660 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1307606 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".