Healthcare Provider Details

I. General information

NPI: 1639791106
Provider Name (Legal Business Name): HOLLY HEAVEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 BROAD ST STE 304
BRIDGEPORT CT
06604-4219
US

IV. Provider business mailing address

PO BOX 11
DERBY CT
06418-0011
US

V. Phone/Fax

Practice location:
  • Phone: 203-545-1582
  • Fax:
Mailing address:
  • Phone: 203-545-1582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: HOLLY HEAVEN
Title or Position: OWNER
Credential: LPC
Phone: 203-545-1582