Provider Demographics
NPI:1316401490
Name:ACHIBONGA, CLETUS (LCSW)
Entity Type:Individual
Prefix:
First Name:CLETUS
Middle Name:
Last Name:ACHIBONGA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 LARCHMONT AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2845
Mailing Address - Country:US
Mailing Address - Phone:720-238-9708
Mailing Address - Fax:203-723-4202
Practice Address - Street 1:35 ELM ST
Practice Address - Street 2:
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-4127
Practice Address - Country:US
Practice Address - Phone:203-723-4133
Practice Address - Fax:203-723-4202
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0104191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical