Healthcare Provider Details

I. General information

NPI: 1437156148
Provider Name (Legal Business Name): IGOR C ESPITTIA LRSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 CHURCH ST
WILLIMANTIC CT
06226-2644
US

IV. Provider business mailing address

PO BOX 191
WILLIMANTIC CT
06226-0191
US

V. Phone/Fax

Practice location:
  • Phone: 864-456-4442
  • Fax: 860-450-4068
Mailing address:
  • Phone: 860-456-4442
  • Fax: 860-456-4068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002725
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: