Provider Demographics
NPI:1306178322
Name:SOUCY, JILL (LCSW)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:SOUCY
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 1:4 PINE TREE LN
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-3620
Mailing Address - Country:US
Mailing Address - Phone:508-254-0527
Mailing Address - Fax:
Practice Address - Street 1:4 PINE TREE LN
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-3620
Practice Address - Country:US
Practice Address - Phone:508-254-0527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-01
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0071931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004051884Medicaid