Healthcare Provider Details

I. General information

NPI: 1255007670
Provider Name (Legal Business Name): ELIZABETH DUTILLY MASON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LIZABETH MASON

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1558 BARNUM AVE
BRIDGEPORT CT
06610-3238
US

IV. Provider business mailing address

1558 BARNUM AVE
BRIDGEPORT CT
06610-3238
US

V. Phone/Fax

Practice location:
  • Phone: 203-384-3377
  • Fax: 203-378-8578
Mailing address:
  • Phone: 203-384-3377
  • Fax: 203-378-8578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11637
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: