Provider Demographics
NPI:1366690109
Name:STOCKWELL, ELIZABETH MARY (LCSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARY
Last Name:STOCKWELL
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 1:300 STATE ST STE 503
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-6133
Mailing Address - Country:US
Mailing Address - Phone:860-271-5283
Mailing Address - Fax:
Practice Address - Street 1:300 STATE ST STE 503
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-6133
Practice Address - Country:US
Practice Address - Phone:860-271-5283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-05
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY085263-1104100000X
MA217650104100000X
CT0119461041C0700X
CT119461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008107739Medicaid