Healthcare Provider Details

I. General information

NPI: 1306159405
Provider Name (Legal Business Name): TOWNSHEND-LACOCK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2010
Last Update Date: 07/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 DURHAM RD
MADISON CT
06443-2675
US

IV. Provider business mailing address

1420 WEST ST
GUILFORD CT
06437-1075
US

V. Phone/Fax

Practice location:
  • Phone: 203-245-8732
  • Fax: 203-457-9465
Mailing address:
  • Phone: 203-245-8732
  • Fax: 203-457-9465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number000940
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number001164
License Number StateCT

VIII. Authorized Official

Name: DR. DARRELL D. LACOCK
Title or Position: PRESIDENT
Credential: PH.D., L.C.S.W.
Phone: 203-245-8732