Provider Demographics
NPI:1114645108
Name:AVALOS, PENELOPE EMMA (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:EMMA
Last Name:AVALOS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 VAUXHALL STREET EXT STE 122
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-4332
Mailing Address - Country:US
Mailing Address - Phone:860-917-0790
Mailing Address - Fax:860-371-2624
Practice Address - Street 1:567 VAUXHALL STREET EXT STE 122
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-4332
Practice Address - Country:US
Practice Address - Phone:860-917-0790
Practice Address - Fax:860-371-2624
Is Sole Proprietor?:No
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0095561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical