Basic Information
| Provider Information | |||||||||
| NPI: | 1225443856 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARDNER | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 LONG WHARF DR STE 321 | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065115946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814600 | ||||||||
| FaxNumber: | 2037814624 | ||||||||
| Practice Location | |||||||||
| Address1: | 1783 MERIDEN WATERBURY TURNPIKE | ||||||||
| Address2: | SUITE K 11 | ||||||||
| City: | SOUTHINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064890268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034041010 | ||||||||
| FaxNumber: | 8604262898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2014 | ||||||||
| LastUpdateDate: | 01/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103TA0400X | N | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 10383 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 004217099 | 05 | CT | MEDICAID | 004041000 | 05 | CT | MEDICAID | 008083698 | 05 | CT | MEDICAID | 008003745 | 05 | CT | MEDICAID |