1366800369 NPI number — MS. KATHERINE WALWORTH MA,BA,LPC

Table of content: MS. KATHERINE WALWORTH MA,BA,LPC (NPI 1366800369)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366800369 NPI number — MS. KATHERINE WALWORTH MA,BA,LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALWORTH
Provider First Name:
KATHERINE
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA,BA,LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALWORTH
Provider Other First Name:
KATHERINE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1366800369
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
58 RIVERS STREET
Provider Second Line Business Mailing Address:
SUITE 10
Provider Business Mailing Address City Name:
MILFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-693-1050
Provider Business Mailing Address Fax Number:
203-306-3388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 ELM ST
Provider Second Line Business Practice Location Address:
UNIT 2
Provider Business Practice Location Address City Name:
STONINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06378-1259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-303-7166
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/04/2016

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: 101YP2500X , with the licence number:  002867 , 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: PENDING . This is a "CIGNA BEHAVIORAL HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING . This is a "MULTI-PLAN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING . This is a "ANTHEM BCBS OF CT BEHAVIORAL HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 13863724 . This is a "CAQH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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