Provider Demographics
NPI:1497877575
Name:WAWRZYNIAK WEBB, KATHLEEN CAROLYN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:CAROLYN
Last Name:WAWRZYNIAK WEBB
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 DALE RD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3659
Mailing Address - Country:US
Mailing Address - Phone:860-878-2028
Mailing Address - Fax:
Practice Address - Street 1:34 DALE RD
Practice Address - Street 2:SUITE 212
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3659
Practice Address - Country:US
Practice Address - Phone:860-878-2028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3003103TC0700X, 103TC2200X, 103TB0200X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTCBHP005780Medicaid