=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891221719
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARY GINNETTI LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2017
-----------------------------------------------------
Last Update Date | 05/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2911 DIXWELL AVE 305A
-----------------------------------------------------
City | HAMDEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06518-3195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-444-4335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2405 WHITNEY AVE APT 408
-----------------------------------------------------
City | HAMDEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06518-3235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | MARY GINNETTI
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 203-444-4335
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 9728
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------