Healthcare Provider Details

I. General information

NPI: 1992096887
Provider Name (Legal Business Name): HARTFORD GAY & LESBIAN HEALTH COLLECTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2011
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1841 BROAD ST
HARTFORD CT
06114-1780
US

IV. Provider business mailing address

1841 BROAD ST.
HARTFORD CT
06114-2094
US

V. Phone/Fax

Practice location:
  • Phone: 860-278-4163
  • Fax: 860-278-5995
Mailing address:
  • Phone: 860-278-4163
  • Fax: 860-278-5995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number0302
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001588
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number007780
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number002904
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR49289
License Number StateCT
# 6
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number000166
License Number StateCT
# 7
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number031112
License Number StateCT

VIII. Authorized Official

Name: MS. LINDA M. ESTABROOK
Title or Position: EXECUTIVE DIRECTOR
Credential: MPH
Phone: 860-278-4163