Healthcare Provider Details

I. General information

NPI: 1578663753
Provider Name (Legal Business Name): MARIA WREN M.S.W., L.C.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 WILLARD AVE
NEWINGTON CT
06111-2631
US

IV. Provider business mailing address

555 WILLARD AVE
NEWINGTON CT
06111-2631
US

V. Phone/Fax

Practice location:
  • Phone: 860-667-6883
  • Fax:
Mailing address:
  • Phone: 860-667-6883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number004704
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: