Healthcare Provider Details

I. General information

NPI: 1134844137
Provider Name (Legal Business Name): JEFFREY ALFONSO GUANCE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 ELM ST
OLD SAYBROOK CT
06475-4105
US

IV. Provider business mailing address

130 ELM ST
OLD SAYBROOK CT
06475-4105
US

V. Phone/Fax

Practice location:
  • Phone: 860-388-9656
  • Fax:
Mailing address:
  • Phone: 860-388-9656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6104
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: