Healthcare Provider Details

I. General information

NPI: 1588682660
Provider Name (Legal Business Name): MARY KINNEY MARSH M.S., L.M.F.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 BRADLEY ST 2ND FLOOR, SUITE 4
BRISTOL CT
06010-5103
US

IV. Provider business mailing address

68 MEDFORD ST
BRISTOL CT
06010-3677
US

V. Phone/Fax

Practice location:
  • Phone: 860-584-1087
  • Fax:
Mailing address:
  • Phone: 860-314-1236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number000656
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: