Healthcare Provider Details

I. General information

NPI: 1407693831
Provider Name (Legal Business Name): VICTORIA HOTHAM LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 E CENTER ST # 2R
MANCHESTER CT
06040-5221
US

IV. Provider business mailing address

185 PINE ST APT 406
MANCHESTER CT
06040-5879
US

V. Phone/Fax

Practice location:
  • Phone: 860-281-1133
  • Fax:
Mailing address:
  • Phone: 860-327-2590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9754
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: