Provider Demographics
NPI:1215040357
Name:SMITH-EZYK, DOLORES ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DOLORES
Middle Name:ANN
Last Name:SMITH-EZYK
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 1:170 ABRAM ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-3821
Mailing Address - Country:US
Mailing Address - Phone:203-380-9255
Mailing Address - Fax:203-380-9255
Practice Address - Street 1:2296 MAIN ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-5974
Practice Address - Country:US
Practice Address - Phone:203-380-9255
Practice Address - Fax:203-380-9255
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003969CT1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT80000081838Medicare ID - Type Unspecified