Basic Information
| Provider Information | |||||||||
| NPI: | 1174961437 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAVERNER | ||||||||
| FirstName: | VIRGINIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 LONG WHARF DR | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065115991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 54 E RAMSDELL ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065151140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033379943 | ||||||||
| FaxNumber: | 2033876533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2013 | ||||||||
| LastUpdateDate: | 10/02/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 000988 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 008023170 | 05 | CT | MEDICAID | 008039745 | 05 | CT | MEDICAID | 008045348 | 01 | TAVERNER MEDICAID | OTHER | 008024427 | 05 | CT | MEDICAID |