Provider Demographics
NPI:1356085765
Name:ROSENBAUM, HEATHER LYN (LCSW)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYN
Last Name:ROSENBAUM
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 1:201 HULLS HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06890-1183
Mailing Address - Country:US
Mailing Address - Phone:203-640-0777
Mailing Address - Fax:
Practice Address - Street 1:201 HULLS HWY
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:CT
Practice Address - Zip Code:06890-1183
Practice Address - Country:US
Practice Address - Phone:203-640-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0101771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010177OtherLICENSED CLINICAL SOCIAL WORKER