Provider Demographics
NPI:1568117919
Name:BIRDSALL, SUNDARI ELLIOTT (LMSW)
Entity Type:Individual
Prefix:
First Name:SUNDARI
Middle Name:ELLIOTT
Last Name:BIRDSALL
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 ANTON RD APT B
Mailing Address - Street 2:
Mailing Address - City:STORRS MANSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06268-1188
Mailing Address - Country:US
Mailing Address - Phone:203-675-4135
Mailing Address - Fax:
Practice Address - Street 1:55 LOCK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3603
Practice Address - Country:US
Practice Address - Phone:203-432-0246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6217104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker