Provider Demographics
NPI:1437469426
Name:HUMBERT, TAYLOR ADAH (LCSW)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ADAH
Last Name:HUMBERT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:
Other - Last Name:PETEKIEWICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:86 WILMONT ST
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1950
Mailing Address - Country:US
Mailing Address - Phone:845-642-4159
Mailing Address - Fax:
Practice Address - Street 1:86 WILMONT ST
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109
Practice Address - Country:US
Practice Address - Phone:845-642-4159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-08
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0089441041C0700X
CTC0920150006421041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1003991019OtherAGENCY'S NPI #
NY00745088OtherAGENCY'S MEDICAID MMIS #