Healthcare Provider Details

I. General information

NPI: 1386134252
Provider Name (Legal Business Name): KATIE MARIE LEDOUX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BULKELEY PL
NEW LONDON CT
06320-6206
US

IV. Provider business mailing address

PO BOX 120
NEW LONDON CT
06320-0120
US

V. Phone/Fax

Practice location:
  • Phone: 860-437-4550
  • Fax:
Mailing address:
  • Phone: 860-437-4550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: