Provider Demographics
NPI:1861010753
Name:IVEZAJ, KRISTI LOUISE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:KRISTI
Middle Name:LOUISE
Last Name:IVEZAJ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 FITCH LN
Mailing Address - Street 2:
Mailing Address - City:NEW CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06840-5052
Mailing Address - Country:US
Mailing Address - Phone:706-761-3998
Mailing Address - Fax:
Practice Address - Street 1:2960 POST RD FL 3
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:CT
Practice Address - Zip Code:06890-1268
Practice Address - Country:US
Practice Address - Phone:203-307-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5253104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker