Basic Information
| Provider Information | |||||||||
| NPI: | 1376030668 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACDONALD | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | FRANCIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 WHEELER RD | ||||||||
| Address2: | |||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061093364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606811180 | ||||||||
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| Practice Location | |||||||||
| Address1: | 317 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060422007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606432101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2018 | ||||||||
| LastUpdateDate: | 04/23/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 3284 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.