Healthcare Provider Details

I. General information

NPI: 1528349651
Provider Name (Legal Business Name): CAROLYN KAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2011
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 WIRE MILL RD STE 20
STAMFORD CT
06903-4412
US

IV. Provider business mailing address

14 DARTLEY ST
STAMFORD CT
06905-3507
US

V. Phone/Fax

Practice location:
  • Phone: 203-921-6653
  • Fax:
Mailing address:
  • Phone: 516-851-6936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number112438388
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number009330
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: