MEDICARE: MS. BONNIE A REDDEROTH MSW, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	002265CT	CT
2	1041C0700X	Clinical Social Worker	002265	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	140002265CT01	OTHER	CT	ANTHEM BCBS

General Provider Information

NPI Number	:	1356484125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BONNIE A REDDEROTH MSW, LCSW

Provider Business Mailing Address
First Line	:	61 S MAIN ST STE 307
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06107-2403
Country	:	US
Telephone Number	:	860-523-0288
Fax Number	:

Provider Business Practice Location Address
First Line	:	61 S MAIN ST STE 307
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06107-2403
Country	:	US
Telephone Number	:	860-523-0288
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	10/03/2023

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