Marie T. Clavecilla-Chan, M.A.

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

001481 Issued in CT

Practice address

100 Market SQ
Suite # 10
Newington, CT 06111-2921

Phone

(860) 665-1025

Fax

(860) 667-6008

NPI assigned

Feb 13, 2007

Last updated

Nov 16, 2007By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• Marie T. Custodio Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Arts

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1171324800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1195171200000",
    "number": "1598807810",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 MARKET SQ",
            "address_2": "SUITE # 10",
            "city": "NEWINGTON",
            "state": "CT",
            "postal_code": "061112921",
            "telephone_number": "860-665-1025",
            "fax_number": "860-667-6008"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 MARKET SQ",
            "address_2": "SUITE # 10",
            "city": "NEWINGTON",
            "state": "CT",
            "postal_code": "061112921",
            "telephone_number": "860-665-1025",
            "fax_number": "860-667-6008"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLAVECILLA-CHAN",
        "first_name": "MARIE",
        "middle_name": "T.",
        "credential": "M.A.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2007-02-13",
        "last_updated": "2007-11-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "CT",
            "license": "001481",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM BEHAVIORAL HEALTH",
            "identifier": "240001481CT01",
            "state": "CT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CT MEDICAL ASSITANCE PROG",
            "identifier": "004257912",
            "state": "CT"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "MARIE",
            "last_name": "CUSTODIO",
            "middle_name": "T.",
            "credential": "M.A.",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Patricia Cioffi, MD
• Seth Thomas Cioffi, PHARM.D.
• Richard Cipolla, H.I.S.
• Elizabeth Sara Citron, LCSW
• Susan C Clark
• Adele I Clay, APRN
• Clinisanitas, PC
• Sandra Ann Coakley, LPC, NCC
• Kim Leslie Cohen, LMFT
• Rachel Lauren Cohen, D.M.D.

• Professional Counselor in Newington, CT
• Providers in Newington, CT by specialty
• Professional Counselor in Connecticut

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 16, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.