Healthcare Provider Details

I. General information

NPI: 1982985685
Provider Name (Legal Business Name): DUSTIN YAGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2011
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

587 E MIDDLE TPKE
MANCHESTER CT
06040-3731
US

IV. Provider business mailing address

995 DAY HILL RD
WINDSOR CT
06095-1722
US

V. Phone/Fax

Practice location:
  • Phone: 860-645-0487
  • Fax: 860-645-7732
Mailing address:
  • Phone: 860-731-5522
  • Fax: 860-731-5536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: