Healthcare Provider Details

I. General information

NPI: 1104066042
Provider Name (Legal Business Name): DIANE J GRACEWSKI LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2009
Last Update Date: 03/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 RESEARCH PKWY C
OLD SAYBROOK CT
06475-4214
US

IV. Provider business mailing address

20 RESEARCH PKWY C
OLD SAYBROOK CT
06475-4214
US

V. Phone/Fax

Practice location:
  • Phone: 800-370-3651
  • Fax: 860-510-0020
Mailing address:
  • Phone: 800-370-3651
  • Fax: 860-510-0020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002292
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: