Healthcare Provider Details

I. General information

NPI: 1235394263
Provider Name (Legal Business Name): LISA WACKERMAN IWANOWSKI LCSW,MSW,BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2008
Last Update Date: 12/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 POST RD STE A11
FAIRFIELD CT
06824-6061
US

IV. Provider business mailing address

1275 POST RD STE A11
FAIRFIELD CT
06824-6061
US

V. Phone/Fax

Practice location:
  • Phone: 203-257-6047
  • Fax:
Mailing address:
  • Phone: 203-257-6047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4411
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: