Provider Demographics
NPI:1437685617
Name:CONCANNON, CAROL (LCSW)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:CONCANNON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:COKEY
Other - Middle Name:
Other - Last Name:CONCANNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:40 OCEAN DR N
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-7838
Mailing Address - Country:US
Mailing Address - Phone:203-918-4889
Mailing Address - Fax:
Practice Address - Street 1:9 BERKELEY ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3916
Practice Address - Country:US
Practice Address - Phone:203-918-4889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-05
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10352104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker