Provider Demographics
NPI:1326107780
Name:IWANICKI, WALTER STEPHEN (MSW)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:STEPHEN
Last Name:IWANICKI
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-4343
Mailing Address - Country:US
Mailing Address - Phone:860-442-3858
Mailing Address - Fax:
Practice Address - Street 1:567 VAUXHALL STREET EXT
Practice Address - Street 2:STE.326
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-4330
Practice Address - Country:US
Practice Address - Phone:860-443-0676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0005101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical