Healthcare Provider Details

I. General information

NPI: 1720851736
Provider Name (Legal Business Name): TERESA LUCILLE DENICHOLAS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2023
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 WASHINGTON AVE STE 203
HAMDEN CT
06518-3272
US

IV. Provider business mailing address

258 OLD LAMBERT RD
ORANGE CT
06477-3526
US

V. Phone/Fax

Practice location:
  • Phone: 203-288-0414
  • Fax:
Mailing address:
  • Phone: 203-815-5779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4999
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: