Provider Demographics
NPI:1972657351
Name:CHACE, AMY B (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:B
Last Name:CHACE
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 903
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:CT
Mailing Address - Zip Code:06234
Mailing Address - Country:US
Mailing Address - Phone:860-230-0771
Mailing Address - Fax:
Practice Address - Street 1:50 ACADEMY HILL ROAD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:CT
Practice Address - Zip Code:06374
Practice Address - Country:US
Practice Address - Phone:860-230-0771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0051581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004256716Medicaid