Provider Demographics
NPI:1154670651
Name:CHANG, TATIANA ANTHONIA (LCSW)
Entity type:Individual
Prefix:MS
First Name:TATIANA
Middle Name:ANTHONIA
Last Name:CHANG
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 1:459 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4219
Mailing Address - Country:US
Mailing Address - Phone:914-882-9647
Mailing Address - Fax:
Practice Address - Street 1:459 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4219
Practice Address - Country:US
Practice Address - Phone:914-882-9647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0184370081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1821059486Medicaid