Provider Demographics
NPI:1528619038
Name:LINDA S MITTENTHAL LCSW LLC
Entity type:Organization
Organization Name:LINDA S MITTENTHAL LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:MITTENTHAL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-517-6633
Mailing Address - Street 1:1738 ELLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2773
Mailing Address - Country:US
Mailing Address - Phone:860-614-0842
Mailing Address - Fax:
Practice Address - Street 1:1738 ELLINGTON RD
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-2773
Practice Address - Country:US
Practice Address - Phone:860-614-0842
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LINDA S MITTENTHAL LCSW LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008034075Medicaid
CT11590385OtherCAQH