Basic Information
Provider Information | |||||||||
NPI: | 1417310673 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SPOONER | ||||||||
FirstName: | TAYLOR | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ADAMS | ||||||||
OtherFirstName: | TAYLOR | ||||||||
OtherMiddleName: | D | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7720 | ||||||||
Address2: | CREDENTIALING SPECIALIST | ||||||||
City: | NEW HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065190720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2035033174 | ||||||||
FaxNumber: | 2035033183 | ||||||||
Practice Location | |||||||||
Address1: | 400 COLUMBUS AVENUE | ||||||||
Address2: | CFG-COLUMBUS AVE | ||||||||
City: | NEW HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065191233 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2035033075 | ||||||||
FaxNumber: | 2035033066 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2016 | ||||||||
LastUpdateDate: | 02/25/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/25/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 9992 | CT | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 000278 | CT | N |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | 004235900 | 05 | CT |   | MEDICAID |