Healthcare Provider Details

I. General information

NPI: 1215005236
Provider Name (Legal Business Name): SANDRA R ROUSSEAU-BICKNELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 08/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DUTTON HOME SILVER ST RIVER VALLEY SERVICES
MIDDLETOWN CT
06457
US

IV. Provider business mailing address

DUTTON HOME SILVER ST PO BOX 351 RIVER VALLEY SERVICES
MIDDLETOWN CT
06457
US

V. Phone/Fax

Practice location:
  • Phone: 860-262-5358
  • Fax: 860-262-5850
Mailing address:
  • Phone: 860-262-5358
  • Fax: 860-262-5850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number005526
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: