Healthcare Provider Details

I. General information

NPI: 1609793777
Provider Name (Legal Business Name): CHARRISSE NICOLE GUDGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 LEROY PL
STAMFORD CT
06902-3116
US

IV. Provider business mailing address

16 LEROY PL
STAMFORD CT
06902-3116
US

V. Phone/Fax

Practice location:
  • Phone: 203-309-9768
  • Fax:
Mailing address:
  • Phone: 203-309-9768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11693
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: