Healthcare Provider Details

I. General information

NPI: 1689163388
Provider Name (Legal Business Name): OMATA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FELLOWS RD APT 47
OAKDALE CT
06370-1624
US

IV. Provider business mailing address

1 FELLOWS RD APT 47
OAKDALE CT
06370-1624
US

V. Phone/Fax

Practice location:
  • Phone: 860-334-5900
  • Fax:
Mailing address:
  • Phone: 860-334-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number46.003444
License Number StateCT

VIII. Authorized Official

Name: MRS. MORGAN ANN AJELLO
Title or Position: OWNER
Credential: LPC, NCC
Phone: 860-334-5900