Healthcare Provider Details

I. General information

NPI: 1194208603
Provider Name (Legal Business Name): CARRIE KOLB, LCSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 03/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 MAIN ST
OLD SAYBROOK CT
06475-2326
US

IV. Provider business mailing address

263 MAIN ST STE 304-306
OLD SAYBROOK CT
06475-2326
US

V. Phone/Fax

Practice location:
  • Phone: 617-571-7979
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: CARRIE KOLB
Title or Position: PSYCHOTHERAPIST
Credential:
Phone: 617-571-7979