Healthcare Provider Details

I. General information

NPI: 1285141077
Provider Name (Legal Business Name): CHRISTINE O'GRADY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

IV. Provider business mailing address

40 WEST ST
MIDDLETOWN CT
06457-3008
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-4825
  • Fax: 860-358-4457
Mailing address:
  • Phone: 860-840-8190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number00985
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: