Healthcare Provider Details

I. General information

NPI: 1164029427
Provider Name (Legal Business Name): LAUREN PETTIT BS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

591 POQUONNOCK RD
GROTON CT
06340-4571
US

IV. Provider business mailing address

PO BOX 120
NEW LONDON CT
06320-0120
US

V. Phone/Fax

Practice location:
  • Phone: 860-437-4550
  • Fax: 860-661-4262
Mailing address:
  • Phone: 860-437-4550
  • Fax: 860-661-4262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: