Provider Demographics
NPI:1255594552
Name:DEITERS, ANN
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:DEITERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 POST RD
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:CT
Mailing Address - Zip Code:06820-3608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1351 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-2419
Practice Address - Country:US
Practice Address - Phone:203-621-3700
Practice Address - Fax:203-621-3710
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004234788Medicaid
CT403OtherSTATE LICENSE