MEDICARE: MARY BETH SUTTER, LCSW, LLC

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	005170	CT

General Provider Information

NPI Number	:	1760570980
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY BETH SUTTER, LCSW, LLC

Provider Business Mailing Address
First Line	:	1 BRADLEY RD
Second Line	:	SUITE 205
City	:	WOODBRIDGE
State	:	CT
Zip	:	06525-2285
Country	:	US
Telephone Number	:	203-397-7973
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 BRADLEY RD
Second Line	:	SUITE 205
City	:	WOODBRIDGE
State	:	CT
Zip	:	06525-2285
Country	:	US
Telephone Number	:	203-397-7973
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARY E WOMER
Credential	:	LCSW
Telephone Number	:	203-397-7973

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	08/22/2020

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