Healthcare Provider Details

I. General information

NPI: 1952053977
Provider Name (Legal Business Name): MARIELIS BRUNO MENDEZ LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2022
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 EDWARDS ST
NEW HAVEN CT
06511-3986
US

IV. Provider business mailing address

6 PERSHING ST
EAST HAVEN CT
06513-2779
US

V. Phone/Fax

Practice location:
  • Phone: 203-777-8648
  • Fax:
Mailing address:
  • Phone: 203-843-3970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6233
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: