Provider Demographics
NPI:1942654900
Name:GOUDREAULT, WENDY K (LCSW)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:K
Last Name:GOUDREAULT
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 1:1343 SULLIVAN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2714
Mailing Address - Country:US
Mailing Address - Phone:860-416-3072
Mailing Address - Fax:
Practice Address - Street 1:1343 SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-2714
Practice Address - Country:US
Practice Address - Phone:860-416-3072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-15
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0013021041C0700X
CT97291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical