Healthcare Provider Details

I. General information

NPI: 1164632477
Provider Name (Legal Business Name): DUDLEY SANDY MAIRS MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 BRIDGE ST
GREENWICH CT
06830-5238
US

IV. Provider business mailing address

60 PALMERS HILL RD
STAMFORD CT
06902-2113
US

V. Phone/Fax

Practice location:
  • Phone: 203-629-2822
  • Fax: 203-629-2940
Mailing address:
  • Phone: 203-324-6167
  • Fax: 203-629-2940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number070737
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: