Basic Information
| Provider Information | |||||||||
| NPI: | 1174240790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERMAN | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | HERMAN | ||||||||
| OtherFirstName: | GRACE | ||||||||
| OtherMiddleName: | G | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 53 SKIPPER LN | ||||||||
| Address2: | |||||||||
| City: | SOUTHINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064892732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608775889 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 73 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | NEW BRITAIN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060521301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602245267 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2022 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 012159 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.