Healthcare Provider Details

I. General information

NPI: 1669627683
Provider Name (Legal Business Name): SHONA K MADDOCKS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 BOLIVIA ST
WILLIMANTIC CT
06226-2843
US

IV. Provider business mailing address

40 BOLIVIA ST
WILLIMANTIC CT
06226-2843
US

V. Phone/Fax

Practice location:
  • Phone: 860-455-8648
  • Fax: 860-423-5353
Mailing address:
  • Phone: 860-455-8648
  • Fax: 860-423-5353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number007993
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: