Healthcare Provider Details

I. General information

NPI: 1821055716
Provider Name (Legal Business Name): JONATHAN A. LUYSTERBORGHS L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 MAIN ST
MIDDLETOWN CT
06457-2718
US

IV. Provider business mailing address

635 MAIN ST
MIDDLETOWN CT
06457-2718
US

V. Phone/Fax

Practice location:
  • Phone: 860-347-6971
  • Fax: 860-638-6601
Mailing address:
  • Phone: 860-347-6971
  • Fax: 860-638-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number004330
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: