Healthcare Provider Details

I. General information

NPI: 1093888497
Provider Name (Legal Business Name): LAURA BALTZELL MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 RESERVOIR OFFICE PARK STE 204
SOUTHBURY CT
06488-3926
US

IV. Provider business mailing address

59 CARMEL HILL RD N
BETHLEHEM CT
06751-1602
US

V. Phone/Fax

Practice location:
  • Phone: 781-308-2259
  • Fax:
Mailing address:
  • Phone: 781-308-2259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1022672
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: