Provider Demographics
NPI:1942329685
Name:EZEKOWITZ, WILMA JOAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:WILMA
Middle Name:JOAN
Last Name:EZEKOWITZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 WASHINGTON AVE
Mailing Address - Street 2:STE 11S
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3025
Mailing Address - Country:US
Mailing Address - Phone:203-230-0824
Mailing Address - Fax:203-248-5360
Practice Address - Street 1:295 WASHINGTON AVE
Practice Address - Street 2:STE 11S
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3025
Practice Address - Country:US
Practice Address - Phone:203-230-0824
Practice Address - Fax:203-287-9502
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001770103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD300127151Medicare PIN