MEDICARE: SELF LOVE THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1053026187
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SELF LOVE THERAPY

Provider Business Mailing Address
First Line	:	PO BOX 1546
Second Line	:
City	:	SOUTH WINDSOR
State	:	CT
Zip	:	06074-7546
Country	:	US
Telephone Number	:	860-837-0302
Fax Number	:

Provider Business Practice Location Address
First Line	:	26 AMATO DR APT C
Second Line	:
City	:	SOUTH WINDSOR
State	:	CT
Zip	:	06074-3657
Country	:	US
Telephone Number	:	860-985-5969
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	AVINA JOHNSON-SMITH
Credential	:	LMFT
Telephone Number	:	860-837-0302

Provider Enumeration Date	:	01/23/2023
Last Update Date	:	01/23/2023

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Directions to “SELF LOVE THERAPY ” Practice Location

Language	Start Address	Practice Location

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