Healthcare Provider Details

I. General information

NPI: 1326107780
Provider Name (Legal Business Name): WALTER STEPHEN IWANICKI MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

567 VAUXHALL STREET EXT STE.326
WATERFORD CT
06385-4330
US

IV. Provider business mailing address

5 MEADOW DR
WATERFORD CT
06385-4343
US

V. Phone/Fax

Practice location:
  • Phone: 860-443-0676
  • Fax:
Mailing address:
  • Phone: 860-442-3858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number000510
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: