Provider Demographics
NPI:1891968285
Name:GRODD, STACEY (MSW,LCSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:GRODD
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 1:264 AMITY RD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-2200
Mailing Address - Country:US
Mailing Address - Phone:203-397-0011
Mailing Address - Fax:
Practice Address - Street 1:264 AMITY RD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:CT
Practice Address - Zip Code:06525-2200
Practice Address - Country:US
Practice Address - Phone:203-397-0011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0036721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT140003672CT01OtherANTHEM BEHAVIORAL HEALTH