Healthcare Provider Details

I. General information

NPI: 1972657351
Provider Name (Legal Business Name): AMY B CHACE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 03/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 ACADEMY HILL ROAD
PLAINFIELD CT
06374
US

IV. Provider business mailing address

PO BOX 903
BROOKLYN CT
06234
US

V. Phone/Fax

Practice location:
  • Phone: 860-230-0771
  • Fax:
Mailing address:
  • Phone: 860-230-0771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number005158
License Number StateCT

VII. Legacy identifiers

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

# 1
Identifier004256716
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: