Provider Demographics
NPI:1225174907
Name:SWIDERSKI, CARRIE (PSYD)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:SWIDERSKI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 COLONIAL RD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-3106
Mailing Address - Country:US
Mailing Address - Phone:860-417-9110
Mailing Address - Fax:
Practice Address - Street 1:1002 GEORGIA ST UNIT 104
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-4364
Practice Address - Country:US
Practice Address - Phone:860-417-9110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT003660101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1307606Medicaid