Provider Demographics
NPI:1598953259
Name:WOOLFOLK, TAWANNA (LCSW)
Entity Type:Individual
Prefix:
First Name:TAWANNA
Middle Name:
Last Name:WOOLFOLK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BOULDER PASS APT 321
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06478-4947
Mailing Address - Country:US
Mailing Address - Phone:203-927-0042
Mailing Address - Fax:
Practice Address - Street 1:140 CAPTAIN THOMAS BLVD STE 211B
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-5951
Practice Address - Country:US
Practice Address - Phone:203-927-0042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0065781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0040399533Medicaid