Healthcare Provider Details

I. General information

NPI: 1871208058
Provider Name (Legal Business Name): MYCHELLE JEWELL CARTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2023
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 REGENCY DR
BLOOMFIELD CT
06002-2310
US

IV. Provider business mailing address

1 REGENCY DR
BLOOMFIELD CT
06002-2310
US

V. Phone/Fax

Practice location:
  • Phone: 860-365-6041
  • Fax:
Mailing address:
  • Phone: 860-365-6041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number002979
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: