Healthcare Provider Details

I. General information

NPI: 1558036764
Provider Name (Legal Business Name): TELETHERAPY SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 BARBARA LN
PLANTSVILLE CT
06479-1654
US

IV. Provider business mailing address

46 BARBARA LN
PLANTSVILLE CT
06479-1654
US

V. Phone/Fax

Practice location:
  • Phone: 860-385-1422
  • Fax: 877-346-8993
Mailing address:
  • Phone: 860-385-1422
  • Fax: 877-346-8993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. KRISTEN S. BIRMINGHAM
Title or Position: OWNER
Credential: MS MFT LADC
Phone: 860-385-1422