Provider Demographics
NPI:1942366018
Name:NISSANKA, SRIMATHIE L (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SRIMATHIE
Middle Name:L
Last Name:NISSANKA
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:PO BOX 2218
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-1618
Mailing Address - Country:US
Mailing Address - Phone:860-646-4889
Mailing Address - Fax:
Practice Address - Street 1:27 HARTFORD TPKE
Practice Address - Street 2:SUITE 208
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-5245
Practice Address - Country:US
Practice Address - Phone:860-646-4889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0039131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0041725400Medicaid
CT0041725400Medicaid