1144513615 NPI number — MRS. SHIRLEY MARIE FRASER LCSW

Table of content: MRS. SHIRLEY MARIE FRASER LCSW (NPI 1144513615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144513615 NPI number — MRS. SHIRLEY MARIE FRASER LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRASER
Provider First Name:
SHIRLEY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NAZARIO
Provider Other First Name:
SHIRLEY
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1144513615
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
173 FARNHAM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH WINDSOR
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06074-1143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-324-4254
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 HARTFORD TPKE
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
VERNON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06066-4719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-324-4254
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/17/2011

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: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 008352 , 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)





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