Provider Demographics
NPI:1861420895
Name:ANDERSON, DIVINA MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:DIVINA
Middle Name:MARIE
Last Name:ANDERSON
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 1:92 VINE ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-1433
Mailing Address - Country:US
Mailing Address - Phone:860-229-4830
Mailing Address - Fax:860-826-8701
Practice Address - Street 1:92 VINE ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1433
Practice Address - Country:US
Practice Address - Phone:203-229-4830
Practice Address - Fax:860-826-8701
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0051901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical