Provider Demographics
NPI:1629005491
Name:GIBBONS, WENDY (LCSW)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:
Other - Last Name:GIBBONS-SHEPRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11 BONSILENE ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-8246
Mailing Address - Country:US
Mailing Address - Phone:203-209-9594
Mailing Address - Fax:
Practice Address - Street 1:949 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3142
Practice Address - Country:US
Practice Address - Phone:203-878-6365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0051831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT279261OtherMHN PROVIDER NUMBER
CT004039244Medicaid