Healthcare Provider Details

I. General information

NPI: 1932255726
Provider Name (Legal Business Name): JIM P MOUTINHO MS LPC LADC NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 FARMINGTON AVE STE 328
FARMINGTON CT
06032-1909
US

IV. Provider business mailing address

PO BOX 270642
WEST HARTFORD CT
06127-0642
US

V. Phone/Fax

Practice location:
  • Phone: 866-887-6864
  • Fax: 866-887-6864
Mailing address:
  • Phone: 866-887-6864
  • Fax: 866-887-6864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number797
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2231
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: