Healthcare Provider Details

I. General information

NPI: 1063812527
Provider Name (Legal Business Name): CAROLE MACKENZIE LCSW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2014
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

674 PROSPECT AVE
HARTFORD CT
06105-4288
US

IV. Provider business mailing address

674 PROSPECT AVE
HARTFORD CT
06105-4288
US

V. Phone/Fax

Practice location:
  • Phone: 860-231-7373
  • Fax: 860-233-5736
Mailing address:
  • Phone: 860-231-7373
  • Fax: 860-233-5736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002083
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number002083
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number002083
License Number StateCT

VIII. Authorized Official

Name: PROF. CAROLE HOLABIRD MACKENZIE
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 860-231-7373