Healthcare Provider Details

I. General information

NPI: 1346772167
Provider Name (Legal Business Name): LORY SETA JOLOLIAN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 DIXWELL AVENUE NORTHSIDE COMMUNITY OUTPATIENT SERVICES
NEW HAVEN CT
06511-3456
US

IV. Provider business mailing address

400 COLUMBUS AVENUE CREDENTIALING SPECIALIST
NEW HAVEN CT
06519-1233
US

V. Phone/Fax

Practice location:
  • Phone: 203-503-3470
  • Fax: 203-503-3478
Mailing address:
  • Phone: 203-503-3174
  • Fax: 203-503-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number007844
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3657
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: