1720143951 NPI number — HECTOR G LIZCANO LCSW LADC

Table of content: HECTOR G LIZCANO LCSW LADC (NPI 1720143951)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720143951 NPI number — HECTOR G LIZCANO LCSW LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIZCANO
Provider First Name:
HECTOR
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW LADC
Provider Gender Code:
M

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:
1720143951
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
152 MAPLE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06405-4517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-494-0333
Provider Business Mailing Address Fax Number:
203-974-5850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
904 STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06511-3921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-624-7710
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/27/2006

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: 101YA0400X , with the licence number:  LADC 000190 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LCSW003861 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 003861 , 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)