Healthcare Provider Details

I. General information

NPI: 1306094297
Provider Name (Legal Business Name): CHARLES F. KIRBY III LMSW-CC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 07/21/2024
Certification Date: 07/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 HAZEL TER STE 11
WOODBRIDGE CT
06525-2240
US

IV. Provider business mailing address

30 HAZEL TER STE 11
WOODBRIDGE CT
06525-2240
US

V. Phone/Fax

Practice location:
  • Phone: 203-819-7650
  • Fax: 203-298-9487
Mailing address:
  • Phone: 203-819-7650
  • Fax: 203-597-8860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMC11253
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: