Healthcare Provider Details

I. General information

NPI: 1144354317
Provider Name (Legal Business Name): DALE COLLINS THIELERT LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 NORTHWEST DR
PLAINVILLE CT
06062-1534
US

IV. Provider business mailing address

191 WRIGHT ROAD
CANTON CT
06019
US

V. Phone/Fax

Practice location:
  • Phone: 860-793-3586
  • Fax: 860-793-3530
Mailing address:
  • Phone: 860-693-1263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number005309
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: