MEDICARE: NALEJ OF SELF

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	251S00000X	Community/Behavioral Health Agency	008581	CT

General Provider Information

NPI Number	:	1801348016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NALEJ OF SELF

Provider Business Mailing Address
First Line	:	19 ARLINGTON ST
Second Line	:
City	:	HARTFORD
State	:	CT
Zip	:	06106
Country	:	US
Telephone Number	:	347-429-5909
Fax Number	:

Provider Business Practice Location Address
First Line	:	19 ARLINGTON ST
Second Line	:
City	:	HARTFORD
State	:	CT
Zip	:	06106-4004
Country	:	US
Telephone Number	:	347-429-5909
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	JELAN A AGNEW
Credential	:
Telephone Number	:	347-429-5909

Provider Enumeration Date	:	11/04/2016
Last Update Date	:	11/04/2016

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