Basic Information
| Provider Information | |||||||||
| NPI: | 1104830892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOUTO | ||||||||
| FirstName: | JYLL | ||||||||
| MiddleName: | ROBIN HERZOG | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 BOSTON AVE | ||||||||
| Address2: | |||||||||
| City: | STRATFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066145246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033843377 | ||||||||
| FaxNumber: | 2033788578 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 BOSTON AVE | ||||||||
| Address2: | |||||||||
| City: | STRATFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066145246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033843377 | ||||||||
| FaxNumber: | 2033788578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 104100000X-SOCIAL WO | CT | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.