Provider Demographics
NPI:1902140890
Name:THACH, STEFANIE LACCONE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STEFANIE
Middle Name:LACCONE
Last Name:THACH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 NICOLL ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-2670
Mailing Address - Country:US
Mailing Address - Phone:203-624-2600
Mailing Address - Fax:203-562-6232
Practice Address - Street 1:235 NICOLL ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-2670
Practice Address - Country:US
Practice Address - Phone:203-624-2600
Practice Address - Fax:203-562-6232
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0073451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical