Provider Demographics
NPI:1356484125
Name:REDDEROTH, BONNIE A (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:A
Last Name:REDDEROTH
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 S MAIN ST STE 307
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2403
Mailing Address - Country:US
Mailing Address - Phone:860-523-0288
Mailing Address - Fax:
Practice Address - Street 1:61 S MAIN ST STE 307
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2403
Practice Address - Country:US
Practice Address - Phone:860-523-0288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002265CT1041C0700X
CT0022651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT140002265CT01OtherANTHEM BCBS