MEDICARE: TRINA L SHUPTAR CLINICAL SOCIAL WORK

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	003180	CT

General Provider Information

NPI Number	:	1891844023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRINA L SHUPTAR CLINICAL SOCIAL WORK

Provider Business Mailing Address
First Line	:	6 COVE RD
Second Line	:
City	:	BROOKFIELD
State	:	CT
Zip	:	06804-1302
Country	:	US
Telephone Number	:	203-775-2300
Fax Number	:	203-775-0173

Provider Business Practice Location Address
First Line	:	6 COVE RD
Second Line	:
City	:	BROOKFIELD
State	:	CT
Zip	:	06804-1302
Country	:	US
Telephone Number	:	203-775-2300
Fax Number	:	203-775-0173

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

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	07/08/2007

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