Healthcare Provider Details

I. General information

NPI: 1538347349
Provider Name (Legal Business Name): AUTHENTIC BALANCE CONSORTIUM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

267 WILLIMANTIC RD SUITE 5
CHAPLIN CT
06235-2516
US

IV. Provider business mailing address

267 WILLIMANTIC RD SUITE 5
CHAPLIN CT
06235-2516
US

V. Phone/Fax

Practice location:
  • Phone: 860-617-2848
  • Fax:
Mailing address:
  • Phone: 860-617-2848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number006609
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number001484
License Number StateCT

VIII. Authorized Official

Name: DR. DIANE TARRICONE
Title or Position: PARTNER
Credential: LPC
Phone: 860-617-2848