Healthcare Provider Details

I. General information

NPI: 1184102469
Provider Name (Legal Business Name): AMY BETH VALES LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMY BETH FULLERTON

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 MAIN ST STE 122
MONROE CT
06468-2872
US

IV. Provider business mailing address

44 OLD SAWMILL RD
TRUMBULL CT
06611-3355
US

V. Phone/Fax

Practice location:
  • Phone: 203-261-7090
  • Fax:
Mailing address:
  • Phone: 203-981-8489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number001980
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: