Provider Demographics
NPI:1467712653
Name:HERASIMOWICZ, MARIA IWONA
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:IWONA
Last Name:HERASIMOWICZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARIA
Other - Middle Name:IWONA
Other - Last Name:HERASIMOWICZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:500 BLUE HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-1500
Mailing Address - Country:US
Mailing Address - Phone:860-714-3701
Mailing Address - Fax:
Practice Address - Street 1:16 COVENTRY ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-1524
Practice Address - Country:US
Practice Address - Phone:860-714-3704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000946101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)