Provider Demographics
NPI:1851498174
Name:BINGHAM, TANYA (MSW)
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:
Last Name:BINGHAM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 SHEFFIELD ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06704-1048
Mailing Address - Country:US
Mailing Address - Phone:203-596-9724
Mailing Address - Fax:
Practice Address - Street 1:36 SHEFFIELD ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06704-1048
Practice Address - Country:US
Practice Address - Phone:203-596-9724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 1041C0700X
CT0071641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT007164OtherSTATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH