MEDICARE: SIDWAY COUNSELING, 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	106H00000X	Marriage & Family Therapist	001484	CT

General Provider Information

NPI Number	:	1881965002
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIDWAY COUNSELING, LLC

Provider Business Mailing Address
First Line	:	76 WESTBURY PARK RD
Second Line	:	SUITE 303E
City	:	WATERTOWN
State	:	CT
Zip	:	06795-2779
Country	:	US
Telephone Number	:	203-525-2091
Fax Number	:	860-417-6099

Provider Business Practice Location Address
First Line	:	76 WESTBURY PARK RD
Second Line	:	SUITE 303E
City	:	WATERTOWN
State	:	CT
Zip	:	06795-2779
Country	:	US
Telephone Number	:	203-525-2091
Fax Number	:	860-417-6099

Authorized Official
Title or Position	:	OWNER
Name	:	MS. SUSAN P SIDWAY
Credential	:	MS, LMFT
Telephone Number	:	203-525-2091

Provider Enumeration Date	:	01/19/2012
Last Update Date	:	01/19/2012

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