Healthcare Provider Details

I. General information

NPI: 1720444888
Provider Name (Legal Business Name): MISS EDISTINE ROBINSON JR.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 LOMBARD ST
NEW HAVEN CT
06513-2910
US

IV. Provider business mailing address

17 MYRTLE AVE FL 2
WEST HAVEN CT
06516-3650
US

V. Phone/Fax

Practice location:
  • Phone: 203-787-2207
  • Fax:
Mailing address:
  • Phone: 203-600-4756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: