Healthcare Provider Details

I. General information

NPI: 1467982504
Provider Name (Legal Business Name): THERAPEUTIC ALLIANCE OF CONNECTICUT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 SOUTH RD STE 125
ENFIELD CT
06082-4414
US

IV. Provider business mailing address

174 SOUTH RD STE 125
ENFIELD CT
06082-4414
US

V. Phone/Fax

Practice location:
  • Phone: 860-966-1004
  • Fax: 860-788-4090
Mailing address:
  • Phone: 860-966-1004
  • Fax: 860-788-4090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number7027
License Number StateCT

VIII. Authorized Official

Name: MR. JULIO RENE DURAN JR.
Title or Position: OWNER
Credential: PMHNP
Phone: 860-966-1004