Basic Information
| Provider Information | |||||||||
| NPI: | 1760805808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUCCIACCIARO | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | BOWMAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOWMAN | ||||||||
| OtherFirstName: | LAURIE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 152 SIMSBURY RD | ||||||||
| Address2: | BUILDING 9, 2ND FLOOR | ||||||||
| City: | AVON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060013777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602693101 | ||||||||
| FaxNumber: | 8602693102 | ||||||||
| Practice Location | |||||||||
| Address1: | 152 SIMSBURY RD | ||||||||
| Address2: | BUILDING 9, 2ND FLOOR | ||||||||
| City: | AVON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060013777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602693101 | ||||||||
| FaxNumber: | 8602693102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2014 | ||||||||
| LastUpdateDate: | 01/24/2014 | ||||||||
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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 | 1041C0700X | 007651 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.