Healthcare Provider Details

I. General information

NPI: 1982955050
Provider Name (Legal Business Name): COUNSELING CENTERS OF NEW ENGLAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2012
Last Update Date: 09/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 AVON MEADOW LN
AVON CT
06001-3753
US

IV. Provider business mailing address

40 AVON MEADOW LN
AVON CT
06001-3753
US

V. Phone/Fax

Practice location:
  • Phone: 860-990-9870
  • Fax:
Mailing address:
  • Phone: 860-990-9870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5047
License Number StateCT

VIII. Authorized Official

Name: MR. PETER R BOURQUE JR.
Title or Position: OWNER
Credential: APRN
Phone: 860-990-9870