Provider Demographics
NPI:1275883613
Name:HART, AVA MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:AVA
Middle Name:MARIE
Last Name:HART
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AVA
Other - Middle Name:MARIE
Other - Last Name:HOLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:51 BROAD ST
Mailing Address - Street 2:FAMILY ADVOCACY PROGRAM
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3204
Mailing Address - Country:US
Mailing Address - Phone:860-358-4825
Mailing Address - Fax:860-358-3403
Practice Address - Street 1:51 BROAD ST
Practice Address - Street 2:FAMILY ADVOCACY PROGRAM
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3204
Practice Address - Country:US
Practice Address - Phone:860-358-4825
Practice Address - Fax:860-358-3403
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0079611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT007961OtherCT LCSW LIC #