Healthcare Provider Details

I. General information

NPI: 1629316492
Provider Name (Legal Business Name): JENNIFER CHARBONNIERLMFT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2013
Last Update Date: 01/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MAIN ST CARRIAGE HOUSE
OLD SAYBROOK CT
06475-2365
US

IV. Provider business mailing address

100 MAIN ST CARRIAGE HOUSE
OLD SAYBROOK CT
06475-2365
US

V. Phone/Fax

Practice location:
  • Phone: 860-388-3520
  • Fax: 860-388-3520
Mailing address:
  • Phone: 860-388-3520
  • Fax: 860-388-3520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number000386
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number000386
License Number StateCT

VIII. Authorized Official

Name: JENNIFER CHARBONNIER
Title or Position: MARITAL & FAMILY THERAPIST
Credential:
Phone: 860-388-3520