Healthcare Provider Details

I. General information

NPI: 1700341021
Provider Name (Legal Business Name): HEART OF WISDOM COUNSELING AND PSYCHOLOGICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2019
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41C NEW LONDON TPKE
GLASTONBURY CT
06033-4206
US

IV. Provider business mailing address

181 NORTH ST
HEBRON CT
06248-1125
US

V. Phone/Fax

Practice location:
  • Phone: 860-288-7041
  • Fax:
Mailing address:
  • Phone: 917-445-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. SMITH KIDKARNDEE
Title or Position: CLINICAL PSYCHOLOGIST/MEMBER
Credential: PSY.D.
Phone: 917-445-6423