Healthcare Provider Details

I. General information

NPI: 1790010288
Provider Name (Legal Business Name): ANDREW DEGLING LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2009
Last Update Date: 10/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 MAIN ST
EAST BERLIN CT
06023-1136
US

IV. Provider business mailing address

147 MAIN ST
EAST BERLIN CT
06023-1136
US

V. Phone/Fax

Practice location:
  • Phone: 860-944-1171
  • Fax: 860-829-1550
Mailing address:
  • Phone: 860-944-1171
  • Fax: 860-829-1550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001763
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: