Provider Demographics
NPI:1922114016
Name:FODEMAN, CHANNE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CHANNE
Middle Name:
Last Name:FODEMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HILLSPOINT ROAD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-4536
Mailing Address - Country:US
Mailing Address - Phone:203-226-3411
Mailing Address - Fax:
Practice Address - Street 1:12 HILLSPOINT ROAD
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4536
Practice Address - Country:US
Practice Address - Phone:203-226-3411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0010721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical