Healthcare Provider Details

I. General information

NPI: 1659629517
Provider Name (Legal Business Name): MEAGEN ELIZABETH YACOBINO LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEAGEN ELIZABETH DIANA LADC

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 S MAIN ST # LL2
CHESHIRE CT
06410-3181
US

IV. Provider business mailing address

680 S MAIN ST STE LL2
CHESHIRE CT
06410-3181
US

V. Phone/Fax

Practice location:
  • Phone: 877-577-3233
  • Fax:
Mailing address:
  • Phone: 877-577-3233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1001
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number002612
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: