MEDICARE: COLLEEN LAHART PORTH 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	007598	CT

General Provider Information

NPI Number	:	1629340450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLEEN LAHART PORTH LCSW

Provider Business Mailing Address
First Line	:	90 N MAIN ST
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06107-1924
Country	:	US
Telephone Number	:	860-561-1175
Fax Number	:	860-561-3382

Provider Business Practice Location Address
First Line	:	90 N MAIN ST
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06107-1924
Country	:	US
Telephone Number	:	860-561-1175
Fax Number	:	860-561-3382

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

Provider Enumeration Date	:	02/09/2012
Last Update Date	:	02/09/2012

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