Healthcare Provider Details

I. General information

NPI: 1649791310
Provider Name (Legal Business Name): IAN ZETTERVALL LPC, LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 BRADLEY ST
BRISTOL CT
06010-5103
US

IV. Provider business mailing address

135 BREWSTER RD
BRISTOL CT
06010-5212
US

V. Phone/Fax

Practice location:
  • Phone: 860-863-1937
  • Fax:
Mailing address:
  • Phone: 860-630-0820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number46.003558
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number001211
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: