Healthcare Provider Details

I. General information

NPI: 1982091781
Provider Name (Legal Business Name): BRYAN D MCCLOSKEY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 MONTAUK AVE
NEW LONDON CT
06320-4906
US

IV. Provider business mailing address

P. O. BOX 390
NEW LONDON CT
06360-6484
US

V. Phone/Fax

Practice location:
  • Phone: 860-271-4700
  • Fax: 860-271-4797
Mailing address:
  • Phone: 860-271-4715
  • Fax: 860-271-4797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3231
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: