Healthcare Provider Details

I. General information

NPI: 1942194170
Provider Name (Legal Business Name): MRS. IVY MARIYAM THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 MAIN ST S STE 201
SOUTHBURY CT
06488-2224
US

IV. Provider business mailing address

9 WALNUT RIDGE RD
NEW FAIRFIELD CT
06812-3214
US

V. Phone/Fax

Practice location:
  • Phone: 203-255-5078
  • Fax:
Mailing address:
  • Phone: 475-296-8690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6939
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: