Provider Demographics
NPI:1619303047
Name:EDDA MCMANUS LCSW LLC
Entity Type:Organization
Organization Name:EDDA MCMANUS LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMANUS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-440-3838
Mailing Address - Street 1:567 VAUXHALL STREET EXT
Mailing Address - Street 2:SUITE 314
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-4330
Mailing Address - Country:US
Mailing Address - Phone:860-440-3838
Mailing Address - Fax:860-381-5099
Practice Address - Street 1:567 VAUXHALL STREET EXT
Practice Address - Street 2:SUITE 314
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-4330
Practice Address - Country:US
Practice Address - Phone:860-440-3838
Practice Address - Fax:860-381-5099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0071691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTCBHP004254Medicaid