Healthcare Provider Details

I. General information

NPI: 1336578681
Provider Name (Legal Business Name): NATHALIA DORIVAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2013
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 MAIN ST STE 122
MONROE CT
06468-2872
US

IV. Provider business mailing address

731 MAIN ST
MONROE CT
06468-2872
US

V. Phone/Fax

Practice location:
  • Phone: 203-261-7090
  • Fax:
Mailing address:
  • Phone: 203-261-7090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number009872
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: