Provider Demographics
NPI:1952417081
Name:ANDERSON-DIAZ, TEODORO (LCSW,LADC,)
Entity Type:Individual
Prefix:MR
First Name:TEODORO
Middle Name:
Last Name:ANDERSON-DIAZ
Suffix:
Gender:M
Credentials:LCSW,LADC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 EASTVIEW ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06114-2312
Mailing Address - Country:US
Mailing Address - Phone:860-956-1761
Mailing Address - Fax:
Practice Address - Street 1:54 EASTVIEW ST
Practice Address - Street 2:210 WETHERSFIELD AVENUE
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06114-2312
Practice Address - Country:US
Practice Address - Phone:860-956-1761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000554101YA0400X
CT0067121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)