Healthcare Provider Details

I. General information

NPI: 1659511095
Provider Name (Legal Business Name): GLORIA DZEROVYCH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2009
Last Update Date: 02/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 DIVISION STREET GRIFFIN HOSPITAL
DERBY CT
06418
US

IV. Provider business mailing address

130 DIVISION STREET GRIFFIN HOSPITAL
DERBY CT
06418
US

V. Phone/Fax

Practice location:
  • Phone: 203-732-7550
  • Fax: 203-732-1550
Mailing address:
  • Phone: 203-732-7550
  • Fax: 203-732-1550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number001149
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: