Healthcare Provider Details

I. General information

NPI: 1245448323
Provider Name (Legal Business Name): THE FAMILY COUNSELING & MEDIATION CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 NEW HAVEN AVE
DERBY CT
06418-2534
US

IV. Provider business mailing address

435 NEW HAVEN AVE
DERBY CT
06418-2534
US

V. Phone/Fax

Practice location:
  • Phone: 203-736-6734
  • Fax: 203-736-6734
Mailing address:
  • Phone: 203-736-6734
  • Fax: 203-736-6734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001119
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number001119
License Number StateCT

VIII. Authorized Official

Name: KARLENE CHISHOLM
Title or Position: OWNER
Credential: LMFT
Phone: 203-736-6734