Healthcare Provider Details

I. General information

NPI: 1669719563
Provider Name (Legal Business Name): JODY M FARRELL MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JODY M FARRELL LPC

II. Dates (important events)

Enumeration Date: 01/11/2013
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 JAMES VINCENT DR
CLINTON CT
06413-1258
US

IV. Provider business mailing address

27 JAMES VINCENT DR
CLINTON CT
06413-1258
US

V. Phone/Fax

Practice location:
  • Phone: 203-640-7809
  • Fax:
Mailing address:
  • Phone: 203-640-7809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number002626
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: