Healthcare Provider Details

I. General information

NPI: 1003569880
Provider Name (Legal Business Name): JESSICA VIVENZIO, LCSW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 02/14/2022
Certification Date: 02/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 HOPE ST APT 11
STAMFORD CT
06906-2607
US

IV. Provider business mailing address

68 HOPE ST APT 11
STAMFORD CT
06906-2607
US

V. Phone/Fax

Practice location:
  • Phone: 413-531-5788
  • Fax:
Mailing address:
  • Phone: 413-531-5788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JESSICA VIVENZIO
Title or Position: LLC OWNER
Credential: LCSW
Phone: 413-531-5788