=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194609313
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA MARIE COSSEBOOM LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2025
-----------------------------------------------------
Last Update Date | 08/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 390 MIDDLEBURY RD STE 2
-----------------------------------------------------
City | MIDDLEBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06762-2634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-558-1143
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 60 HAZEL DR UNIT 117
-----------------------------------------------------
City | CHESHIRE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06410-1071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 774-608-6037
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 15541
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------