Provider Demographics
NPI:1598807810
Name:CLAVECILLA-CHAN, MARIE T (MA)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:T
Last Name:CLAVECILLA-CHAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:T
Other - Last Name:CUSTODIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:100 MARKET SQ
Mailing Address - Street 2:SUITE # 10
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2921
Mailing Address - Country:US
Mailing Address - Phone:860-665-1025
Mailing Address - Fax:860-667-6008
Practice Address - Street 1:100 MARKET SQ
Practice Address - Street 2:SUITE # 10
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2921
Practice Address - Country:US
Practice Address - Phone:860-665-1025
Practice Address - Fax:860-667-6008
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001481101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT240001481CT01OtherANTHEM BEHAVIORAL HEALTH
CT004257912OtherCT MEDICAL ASSITANCE PROG