Healthcare Provider Details

I. General information

NPI: 1093753808
Provider Name (Legal Business Name): DEBRA M MORDECAI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEBRA M CARROLL LCSW

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 05/01/2022
Certification Date: 05/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 WEST AVON ROAD SUITE 204
AVON CT
06001-3679
US

IV. Provider business mailing address

46 WEST AVON ROAD SUITE 204
AVON CT
06001-3679
US

V. Phone/Fax

Practice location:
  • Phone: 860-307-8943
  • Fax: 860-824-1469
Mailing address:
  • Phone: 860-307-8943
  • Fax: 860-824-1469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number005693
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: