Provider Demographics
NPI:1780837989
Name:WAMPLER, JEREMY S (LCSW, LADC)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:S
Last Name:WAMPLER
Suffix:
Gender:M
Credentials:LCSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 RIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2116
Mailing Address - Country:US
Mailing Address - Phone:203-623-3491
Mailing Address - Fax:
Practice Address - Street 1:205 ORANGE ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-2069
Practice Address - Country:US
Practice Address - Phone:203-776-9900
Practice Address - Fax:203-787-5599
Is Sole Proprietor?:No
Enumeration Date:2008-10-31
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0076681041C0700X
CT000930101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)