MEDICARE: MRS. LAURA BURTT HETHERINGTON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1649288655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURA BURTT HETHERINGTON LCSW

Provider Business Mailing Address
First Line	:	296 AL HARVEY RD
Second Line	:
City	:	STONINGTON
State	:	CT
Zip	:	06378-1902
Country	:	US
Telephone Number	:	860-917-5054
Fax Number	:

Provider Business Practice Location Address
First Line	:	11 MAIN ST STE 11-211A
Second Line	:
City	:	MYSTIC
State	:	CT
Zip	:	06355-3654
Country	:	US
Telephone Number	:	860-415-6165
Fax Number	:	860-701-3776

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	12/14/2022

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