Healthcare Provider Details

I. General information

NPI: 1730379256
Provider Name (Legal Business Name): PATRICK JOSEPH LYTTLE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 07/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 BUCKLAND RD C/O DR. SHAPIRO
SOUTH WINDSOR CT
06074-3720
US

IV. Provider business mailing address

PO BOX 219
GLASTONBURY CT
06033-0219
US

V. Phone/Fax

Practice location:
  • Phone: 860-212-2962
  • Fax:
Mailing address:
  • Phone: 860-212-2962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002802
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: