Provider Demographics
NPI:1134375850
Name:SUPPIES, CRISTINE E (LCSW)
Entity type:Individual
Prefix:
First Name:CRISTINE
Middle Name:E
Last Name:SUPPIES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CRISTINE
Other - Middle Name:ELIZABETH
Other - Last Name:HINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:155 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4548
Mailing Address - Country:US
Mailing Address - Phone:860-659-3553
Mailing Address - Fax:860-659-0744
Practice Address - Street 1:98-100 YORK STREET
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06460
Practice Address - Country:US
Practice Address - Phone:203-785-6862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-13
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW1267301041C0700X
CT0082631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1134375850Medicaid