Basic Information
| Provider Information | |||||||||
| NPI: | 1942302526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANG | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 SUSAN LN | ||||||||
| Address2: | |||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064506848 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 56 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037551196 | ||||||||
| FaxNumber: | 2035759675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 000518 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 134082 | 01 | CT | VALUE OPTIONS | OTHER | 77ABH0006CT08 | 01 | CT | ANTHEM BC/BS | OTHER | 297232 | 01 | CT | MHN | OTHER |