Provider Demographics
NPI:1083919922
Name:CARRA, BRETT G (LCSW)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:G
Last Name:CARRA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 MOUNTAIN RD 2ND FLOOR
Mailing Address - Street 2:
Mailing Address - City:SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06078-2084
Mailing Address - Country:US
Mailing Address - Phone:413-204-4278
Mailing Address - Fax:
Practice Address - Street 1:133 MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SUFFIELD
Practice Address - State:CT
Practice Address - Zip Code:06078
Practice Address - Country:US
Practice Address - Phone:860-698-1150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3136291041C0700X
CT90901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1508908229Medicaid