Healthcare Provider Details

I. General information

NPI: 1396126009
Provider Name (Legal Business Name): KRYSTLE JANINE GEORGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10J TOWNHOUSE RD
BROAD BROOK CT
06016-9698
US

IV. Provider business mailing address

14 HAZARD AVE STE 23
ENFIELD CT
06082-3713
US

V. Phone/Fax

Practice location:
  • Phone: 860-222-0957
  • Fax:
Mailing address:
  • Phone: 860-222-0957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6816
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: