Healthcare Provider Details

I. General information

NPI: 1275004012
Provider Name (Legal Business Name): YABNEEL MARRERO-CANALES LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 MAIN ST STE 1H
WILLIMANTIC CT
06226-3152
US

IV. Provider business mailing address

PO BOX 223
LEBANON CT
06249-0223
US

V. Phone/Fax

Practice location:
  • Phone: 860-639-7711
  • Fax:
Mailing address:
  • Phone: 860-639-7711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4440
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number011113
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: