Healthcare Provider Details

I. General information

NPI: 1639102403
Provider Name (Legal Business Name): ROSE I VAZQUEZ-SANTIAGO LCSW,ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 GAYLORD FARM RD
WALLINGFORD CT
06492-2899
US

IV. Provider business mailing address

PO BOX 400
WALLINGFORD CT
06492-7048
US

V. Phone/Fax

Practice location:
  • Phone: 203-284-2800
  • Fax: 203-294-8734
Mailing address:
  • Phone: 203-284-2800
  • Fax: 203-294-8734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number00-388689
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: