MEDICARE: WE-MPACT LLC

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	103K00000X	Behavior Analyst	000562	CT
2	251S00000X	Community/Behavioral Health Agency	000562	CT

General Provider Information

NPI Number	:	1871819631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WE-MPACT LLC

Provider Business Mailing Address
First Line	:	258 MIDDLE ST
Second Line	:	SUITE C
City	:	BRISTOL
State	:	CT
Zip	:	06010-7492
Country	:	US
Telephone Number	:	860-940-4838
Fax Number	:

Provider Business Practice Location Address
First Line	:	258 MIDDLE ST
Second Line	:	SUITE C
City	:	BRISTOL
State	:	CT
Zip	:	06010-7492
Country	:	US
Telephone Number	:	860-940-4838
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MS. BETTE J KOZAK
Credential	:	LPC
Telephone Number	:	860-940-4838

Provider Enumeration Date	:	04/19/2010
Last Update Date	:	04/19/2010

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Directions to “WE-MPACT LLC ” Practice Location

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