Healthcare Provider Details

I. General information

NPI: 1386006013
Provider Name (Legal Business Name): MY STORY COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 MAIN ST
ELLINGTON CT
06029-3360
US

IV. Provider business mailing address

16 MAIN ST
ELLINGTON CT
06029-3360
US

V. Phone/Fax

Practice location:
  • Phone: 860-871-5402
  • Fax: 860-871-5413
Mailing address:
  • Phone: 860-871-5402
  • Fax: 860-871-5413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number001776
License Number StateCT

VIII. Authorized Official

Name: MS. NOVIA MCLAREN
Title or Position: OWNER/MARRIAGE AND FAMILY THERAPIST
Credential: LMFT
Phone: 860-985-5729