Provider Demographics
NPI:1770824757
Name:BIZOR, LATANYA (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:LATANYA
Middle Name:
Last Name:BIZOR
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:969 W MAIN ST
Mailing Address - Street 2:SUITE 2G
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2653
Mailing Address - Country:US
Mailing Address - Phone:475-275-8245
Mailing Address - Fax:844-364-4330
Practice Address - Street 1:969 W MAIN ST
Practice Address - Street 2:SUITE 2G
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2653
Practice Address - Country:US
Practice Address - Phone:475-275-8245
Practice Address - Fax:844-364-4330
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-15
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CT0093031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008063915Medicaid