Healthcare Provider Details

I. General information

NPI: 1396289344
Provider Name (Legal Business Name): ATLAS OUTLOOK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2016
Last Update Date: 12/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1429 PARK ST RESET FIRST FLOOR
HARTFORD CT
06106-2236
US

IV. Provider business mailing address

1429 PARK ST RESET FIRST FLOOR
HARTFORD CT
06106-2236
US

V. Phone/Fax

Practice location:
  • Phone: 860-685-1254
  • Fax:
Mailing address:
  • Phone: 860-685-1254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number002560
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number001390
License Number StateCT

VIII. Authorized Official

Name: TAMI MENDEZ
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 860-685-1254