Basic Information
| Provider Information | |||||||||
| NPI: | 1225374945 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRINCKERHOFF | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MSW,BA,LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 4TH FLOOR ADMINISTRATION | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 3RD FLOOR HOME BASED SERVICES | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035750466 | ||||||||
| FaxNumber: | 2035751817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2012 | ||||||||
| LastUpdateDate: | 08/25/2016 | ||||||||
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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 | 1041C0700X | 9065 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 060669107 | 01 | CT | UBH-OXFORD HEALTH/LIBERTY/FREEDOM WELLMORE GRP/FACILITY | OTHER | D339209-141 E MAIN | 01 | CT | VALUE OPTIONS | OTHER | PENDING | 01 | CT | MHN MANAGED HEALTH NETWORK | OTHER | PENDING | 01 | CT | MHN-TRICARE NORTH | OTHER | 060669107 | 01 | CT | HEALTHYCT WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | UBH-CONNECTICUT WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | UNITED BEHAVIORAL HEALTH WELLMORE GRP/FACILITY | OTHER | 008060530 | 05 | CT | MEDICAID | PENDING | 01 | CT | AETNA BEHAVIORAL HEALTH | OTHER | PENDING | 01 | CT | CIGNA BEHAVIORAL HEALTH | OTHER | 060669107 | 01 | CT | UBH-UNITED HEALTHCARE WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | ANTHEM BCBS OF CT WELLMORE GRP/FACILITY | OTHER | 13646056 | 01 | CT | CAQH | OTHER |