Healthcare Provider Details

I. General information

NPI: 1225354988
Provider Name (Legal Business Name): SHORELINE CENTER FOR FAMILY COUNSELING & PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 10/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 BUSINESS PARK DR
BRANFORD CT
06405-2931
US

IV. Provider business mailing address

9 BUSINESS PARK DR
BRANFORD CT
06405-2931
US

V. Phone/Fax

Practice location:
  • Phone: 203-433-0299
  • Fax: 203-643-2042
Mailing address:
  • Phone: 203-433-0299
  • Fax: 203-643-2042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number006202
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number005763
License Number StateCT

VIII. Authorized Official

Name: DAVID EWING
Title or Position: OWNER
Credential: LCSW
Phone: 203-433-0299