Healthcare Provider Details

I. General information

NPI: 1437413093
Provider Name (Legal Business Name): GANIKA THERAPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2012
Last Update Date: 06/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44R LEBANON RD
BOZRAH CT
06334-1148
US

IV. Provider business mailing address

44R LEBANON RD
BOZRAH CT
06334-1148
US

V. Phone/Fax

Practice location:
  • Phone: 860-333-1388
  • Fax: 710-456-3471
Mailing address:
  • Phone: 860-333-1388
  • Fax: 710-456-3471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number006591
License Number StateCT

VIII. Authorized Official

Name: MRS. KATHLEEN DOUGLAS
Title or Position: LCSW
Credential:
Phone: 860-333-1388