Provider Demographics
NPI:1710189105
Name:VIVANCO, KATHERINE H (EDM, MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:H
Last Name:VIVANCO
Suffix:
Gender:F
Credentials:EDM, MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 W MAIN ST
Mailing Address - Street 2:SUITE 106B
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-4501
Mailing Address - Country:US
Mailing Address - Phone:203-321-9119
Mailing Address - Fax:
Practice Address - Street 1:2001 W MAIN ST
Practice Address - Street 2:SUITE 106B
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-4501
Practice Address - Country:US
Practice Address - Phone:203-321-9119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT71211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical