Healthcare Provider Details

I. General information

NPI: 1922435676
Provider Name (Legal Business Name): MALYNA KETTAVONG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2013
Last Update Date: 08/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 TOWN ST
NORWICH CT
06360-2315
US

IV. Provider business mailing address

47 TOWN ST
NORWICH CT
06360-2315
US

V. Phone/Fax

Practice location:
  • Phone: 860-892-7042
  • Fax:
Mailing address:
  • Phone: 860-892-7042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8972
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: