Healthcare Provider Details

I. General information

NPI: 1770122954
Provider Name (Legal Business Name): ELIZABETH MARY HRUBIEC RETANO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2020
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1176 FARMINGTON AVENUE
BERLIN CT
06037-2302
US

IV. Provider business mailing address

463 SOUTHINGTON RD
KENSINGTON CT
06037-3422
US

V. Phone/Fax

Practice location:
  • Phone: 860-515-8260
  • Fax:
Mailing address:
  • Phone: 860-209-1231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number003450
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number003450
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: