Healthcare Provider Details

I. General information

NPI: 1558545491
Provider Name (Legal Business Name): NORTHEASTPSYCHOTHERAPY ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 ACADEMY HILL RD UNIT D
PLAINFIELD CT
06374-1600
US

IV. Provider business mailing address

50 ACADEMY HILL RD UNIT D
PLAINFIELD CT
06374-1600
US

V. Phone/Fax

Practice location:
  • Phone: 860-230-0771
  • Fax:
Mailing address:
  • Phone: 860-230-0771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number000612
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. PHILIP H BROWN
Title or Position: MANAGER/MEMBER
Credential: MSW, LCSW
Phone: 860-230-0771