MEDICARE: MRS. KIMBERLY PATTERSON MISHRIKY 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	006850	OTHER	CT	STATE LICENCE

General Provider Information

NPI Number	:	1396994455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY PATTERSON MISHRIKY LCSW

Provider Business Mailing Address
First Line	:	10 CANDLELIGHT DR
Second Line	:
City	:	GLASTONBURY
State	:	CT
Zip	:	06033-2537
Country	:	US
Telephone Number	:	860-633-3595
Fax Number	:

Provider Business Practice Location Address
First Line	:	15 MERCER AVE
Second Line	:	SCHOOL BASED HEALTH CENTER
City	:	EAST HARTFORD
State	:	CT
Zip	:	06118-1517
Country	:	US
Telephone Number	:	860-622-5513
Fax Number	:

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

Provider Enumeration Date	:	09/15/2008
Last Update Date	:	09/18/2008

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