Provider Demographics
NPI:1417469446
Name:ANDERSON, GLORIMAR
Entity Type:Individual
Prefix:
First Name:GLORIMAR
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 FLANDERS RD STE 2D
Mailing Address - Street 2:
Mailing Address - City:EAST LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06333-1727
Mailing Address - Country:US
Mailing Address - Phone:860-514-1935
Mailing Address - Fax:
Practice Address - Street 1:314 FLANDERS RD STE 2D
Practice Address - Street 2:
Practice Address - City:EAST LYME
Practice Address - State:CT
Practice Address - Zip Code:06333-1727
Practice Address - Country:US
Practice Address - Phone:860-514-1935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2022-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT102481041C0700X
CT3419390200000X
CT0102481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010248OtherSTATE OF CONNECTICUT DPH
CT3419OtherSTATE OF CONNECTICUT DPH
CT10248OtherSTATE OF CONNECTICUT DPH