Healthcare Provider Details

I. General information

NPI: 1588142616
Provider Name (Legal Business Name): ISABELLA R FASIHUDDIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ISABELLA RANDAZZO

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 860-281-1133
  • Fax: 860-650-0655
Mailing address:
  • Phone: 860-281-1133
  • Fax: 860-650-0655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11868
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: