Healthcare Provider Details

I. General information

NPI: 1154542140
Provider Name (Legal Business Name): SELBE POTTER RUGGIERO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 NARROW ROCKS RD
WESTPORT CT
06880-6016
US

IV. Provider business mailing address

18 NARROW ROCKS RD
WESTPORT CT
06880-6016
US

V. Phone/Fax

Practice location:
  • Phone: 203-434-1370
  • Fax:
Mailing address:
  • Phone: 203-307-3030
  • Fax: 203-255-7486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002652
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: