Provider Demographics
NPI:1104830892
Name:SOUTO, JYLL ROBIN HERZOG (LCSW)
Entity Type:Individual
Prefix:
First Name:JYLL
Middle Name:ROBIN HERZOG
Last Name:SOUTO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 BOSTON AVE
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-5246
Mailing Address - Country:US
Mailing Address - Phone:203-384-3377
Mailing Address - Fax:203-378-8578
Practice Address - Street 1:305 BOSTON AVE
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-5246
Practice Address - Country:US
Practice Address - Phone:203-384-3377
Practice Address - Fax:203-378-8578
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT104100000X-SOCIAL WO104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT680001384Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER