Provider Demographics
NPI:1538219092
Name:HART, MARJORIE GLOSBAND (LCSW)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:GLOSBAND
Last Name:HART
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 1:35 SHERWOOD TER
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-2123
Mailing Address - Country:US
Mailing Address - Phone:203-453-9977
Mailing Address - Fax:
Practice Address - Street 1:35 SHERWOOD TER
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2123
Practice Address - Country:US
Practice Address - Phone:203-214-9554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0030371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT800003493Medicare ID - Type Unspecified