Provider Demographics
NPI:1326314154
Name:JANE, CORINA (LCSW)
Entity Type:Individual
Prefix:
First Name:CORINA
Middle Name:
Last Name:JANE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CORINA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:18 WITHEY HILL RD
Mailing Address - Street 2:
Mailing Address - City:MOOSUP
Mailing Address - State:CT
Mailing Address - Zip Code:06354-1316
Mailing Address - Country:US
Mailing Address - Phone:860-972-6970
Mailing Address - Fax:
Practice Address - Street 1:18 WITHEY HILL RD
Practice Address - Street 2:
Practice Address - City:MOOSUP
Practice Address - State:CT
Practice Address - Zip Code:06354-1316
Practice Address - Country:US
Practice Address - Phone:860-886-0567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT85821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT58008582OtherCT DPH