Healthcare Provider Details

I. General information

NPI: 1982349320
Provider Name (Legal Business Name): ADVANCED PSYCHOTHERAPY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2022
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3380 MAIN ST
STRATFORD CT
06614-4860
US

IV. Provider business mailing address

193 QUINNIPIAC ST APT 2
WALLINGFORD CT
06492-3767
US

V. Phone/Fax

Practice location:
  • Phone: 203-526-1959
  • Fax: 203-549-0640
Mailing address:
  • Phone: 203-908-1076
  • Fax: 203-526-1959

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 Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: LESHAE RICE
Title or Position: OWNER
Credential: MS LPC-A LADC
Phone: 203-908-1076