Provider Demographics
NPI:1235394263
Name:IWANOWSKI, LISA WACKERMAN (LCSW,MSW,BA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:WACKERMAN
Last Name:IWANOWSKI
Suffix:
Gender:F
Credentials:LCSW,MSW,BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 POST RD STE A11
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-6061
Mailing Address - Country:US
Mailing Address - Phone:203-257-6047
Mailing Address - Fax:
Practice Address - Street 1:1275 POST RD STE A11
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6061
Practice Address - Country:US
Practice Address - Phone:203-257-6047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT44111041C0700X
CT0044111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT12427443OtherCAQH
CTPENDINGOtherAETNA BEHAVIORAL HEALTH
CTPENDINGOtherMHN MANAGED HEALTH NETWORK
CT060669107OtherANTHEM BCBS OF CT WELLMORE GRP/FACILITY
CT060669107OtherUBH-CONNECTICARE WELLMORE GRP/FACILITY
CT4299867OtherCIGNA BEHAVIORAL HEALTH
CT008057192Medicaid
CT060669107OtherUBH- UNITED HEALTHCARE WELLMORE GRP/FACILITY
CT060669107OtherUBH-OXFORD FREEDOM/LIBERTY WELLMORE GRP/FACILITY
CT060669107OtherHEALTHYCT WELLMORE GRP/FACILITY
CTD339123-141 E MAINOtherBEACON HEALTH STRATEGIES
CTPENDINGOtherMHN TRICARENORTH
CT060669107OtherOPTUM BEHAVIORAL HEALTH/UBH WELLMORE GRP/FACILITY
CT060669107OtherUBH-OXFORD FREEDOM/LIBERTY WELLMORE GRP/FACILITY