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General NPI Number Information
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NPI Number | 1780155119
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Entity Type | Individual
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Provider Name | KATHLEEN ROACH-SEPERACK LCSW
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Gender | Female
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Dates
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Enumeration Date | 12/11/2018
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Last Update Date | 06/14/2021
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Provider Practice Location Address
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Address Line | 7-9 ISAAC ST
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City | NORWALK
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State | CT
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Zip | 06850-4102
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Country | US
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Telephone | 203-673-9173
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Fax |
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Provider Business Mailing Address
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Address Line | 235 GROVERS AVE
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City | BRIDGEPORT
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State | CT
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Zip | 06605-3452
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Country | US
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Telephone | 203-673-9173
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 006715
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License Number State | CT
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