Healthcare Provider Details

I. General information

NPI: 1104420306
Provider Name (Legal Business Name): LINDSEY BLAIVAS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2020
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 RIVERSIDE AVE
WESTPORT CT
06880-4242
US

IV. Provider business mailing address

36 HYDE LN
WESTPORT CT
06880-3916
US

V. Phone/Fax

Practice location:
  • Phone: 917-232-7605
  • Fax:
Mailing address:
  • Phone: 917-232-7605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number5487
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13307
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: