Healthcare Provider Details

I. General information

NPI: 1013377183
Provider Name (Legal Business Name): CLUNY GOMBAR LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 05/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 COLUMBUS AVE
NEW HAVEN CT
06519-1233
US

IV. Provider business mailing address

PO BOX 7720 CREDENTIALING SPECIALIST
NEW HAVEN CT
06519-0720
US

V. Phone/Fax

Practice location:
  • Phone: 203-503-3055
  • Fax: 203-503-3066
Mailing address:
  • Phone: 203-503-3174
  • Fax: 203-503-3183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number002911
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: