Basic Information
| Provider Information | |||||||||
| NPI: | 1306094297 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIRBY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | F. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | LMSW-CC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 HAZEL TER STE 11 | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065252240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038197650 | ||||||||
| FaxNumber: | 2035978860 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 HAZEL TER STE 11 | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065252240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038197650 | ||||||||
| FaxNumber: | 2032989487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2008 | ||||||||
| LastUpdateDate: | 11/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | MC11253 | ME | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.