Provider Demographics
NPI:1184930901
Name:SOUTHWORTH, MARTA (BSW, MSW, LCSW, CBIS)
Entity type:Individual
Prefix:MRS
First Name:MARTA
Middle Name:
Last Name:SOUTHWORTH
Suffix:
Gender:F
Credentials:BSW, MSW, LCSW, CBIS
Other - Prefix:MS
Other - First Name:MARTA
Other - Middle Name:
Other - Last Name:GRALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSW, MSW
Mailing Address - Street 1:6 PINECREST DR
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-3251
Mailing Address - Country:US
Mailing Address - Phone:860-305-3585
Mailing Address - Fax:
Practice Address - Street 1:41 S MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2448
Practice Address - Country:US
Practice Address - Phone:860-305-3585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8984104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker