Healthcare Provider Details

I. General information

NPI: 1053026187
Provider Name (Legal Business Name): SELF LOVE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 N MAIN ST STE E
MANCHESTER CT
06042-1973
US

IV. Provider business mailing address

543 N MAIN ST STE E
MANCHESTER CT
06042-1973
US

V. Phone/Fax

Practice location:
  • Phone: 860-837-0302
  • Fax:
Mailing address:
  • Phone: 860-837-0302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: AVINA JOHNSON-SMITH
Title or Position: THERAPIST
Credential: LMFT
Phone: 860-837-0302