Basic Information
| Provider Information | |||||||||
| NPI: | 1871009563 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOFORTH | ||||||||
| FirstName: | OLIVIA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 COLUMBUS AVENUE | ||||||||
| Address2: | CREDENTIALING SPECIALIST | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033174 | ||||||||
| FaxNumber: | 2035036515 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 WAKELEE AVENUE | ||||||||
| Address2: | ANSONIA COUNSELING SERVICES | ||||||||
| City: | ANSONIA | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064011198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033650 | ||||||||
| FaxNumber: | 2035033659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2017 | ||||||||
| LastUpdateDate: | 09/05/2019 | ||||||||
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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 | 10636 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 008089787 | 05 | CT | MEDICAID |