Healthcare Provider Details

I. General information

NPI: 1154492304
Provider Name (Legal Business Name): HOLLY CYR CISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 MONTAUK AVE
NEW LONDON CT
06320-4700
US

IV. Provider business mailing address

365 MONTAUK AVE
NEW LONDON CT
06320-4700
US

V. Phone/Fax

Practice location:
  • Phone: 860-442-0711
  • Fax: 860-444-4767
Mailing address:
  • Phone: 860-442-0711
  • Fax: 860-444-4767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4124
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: