Provider Demographics
NPI:1588440432
Name:AWWA, CORYDON ALI (LMFT)
Entity type:Individual
Prefix:MR
First Name:CORYDON
Middle Name:ALI
Last Name:AWWA
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 CASE STREET
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360
Mailing Address - Country:US
Mailing Address - Phone:860-437-6914
Mailing Address - Fax:860-437-6921
Practice Address - Street 1:616 GOLD STAR HIGHWAY
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340
Practice Address - Country:US
Practice Address - Phone:860-437-6914
Practice Address - Fax:860-437-6921
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003189106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty