Healthcare Provider Details

I. General information

NPI: 1821368945
Provider Name (Legal Business Name): MARK THOMAS BUGNACKI LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 N MAIN ST STE 2A
SOUTHINGTON CT
06489-2572
US

IV. Provider business mailing address

395 SHUTTLE MEADOW AVE
NEW BRITAIN CT
06052-1844
US

V. Phone/Fax

Practice location:
  • Phone: 860-276-3000
  • Fax:
Mailing address:
  • Phone: 860-224-3990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number002096
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: