Healthcare Provider Details

I. General information

NPI: 1679419378
Provider Name (Legal Business Name): ELIZABETH KEYES CHARLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2026
Last Update Date: 04/25/2026
Certification Date: 04/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 MAIN ST STE 1
DURHAM CT
06422-1653
US

IV. Provider business mailing address

350 MAIN ST STE 1
DURHAM CT
06422-1653
US

V. Phone/Fax

Practice location:
  • Phone: 203-200-0437
  • Fax:
Mailing address:
  • Phone: 203-200-0437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number009522
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: