Healthcare Provider Details

I. General information

NPI: 1043920911
Provider Name (Legal Business Name): EDEN CORRIDON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2022
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 MAPLETON AVE
SUFFIELD CT
06078-1343
US

IV. Provider business mailing address

1480 MAPLETON AVE
SUFFIELD CT
06078-1343
US

V. Phone/Fax

Practice location:
  • Phone: 860-214-7997
  • Fax:
Mailing address:
  • Phone: 860-214-7997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5962
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: