Healthcare Provider Details

I. General information

NPI: 1013038116
Provider Name (Legal Business Name): YADIRAH HADDOCK M. A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

896 ASYLUM AVE
HARTFORD CT
06105-1901
US

IV. Provider business mailing address

22 HAVILAND STREET
BRISTOL CT
06010
US

V. Phone/Fax

Practice location:
  • Phone: 860-522-8241
  • Fax: 860-524-8143
Mailing address:
  • Phone: 860-985-0457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: