Healthcare Provider Details

I. General information

NPI: 1336697200
Provider Name (Legal Business Name): JAIME BLISS GUILMETTE, LCSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SHUNPIKE RD SUITE 207
CROMWELL CT
06416-4401
US

IV. Provider business mailing address

80 SHUNPIKE RD SUITE 207
CROMWELL CT
06416-4401
US

V. Phone/Fax

Practice location:
  • Phone: 860-798-4963
  • Fax: 860-852-5904
Mailing address:
  • Phone: 860-798-4963
  • Fax: 860-852-5904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number006582
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier004272316
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer
# 2
Identifier1346420452
Identifier TypeOTHER
Identifier StateCT
Identifier IssuerNPI

VIII. Authorized Official

Name: MRS. JAIME BLISS GUILMETTE
Title or Position: OWNER
Credential: LCSW
Phone: 860-798-4963