Provider Demographics
NPI:1225412828
Name:BIBEAULT, MINA (LCSW)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:BIBEAULT
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 1:8 BYRAM TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06831-5126
Mailing Address - Country:US
Mailing Address - Phone:203-857-9495
Mailing Address - Fax:
Practice Address - Street 1:75 HOLLY HILL LN STE 100
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-2917
Practice Address - Country:US
Practice Address - Phone:203-857-9495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0090021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical