Healthcare Provider Details

I. General information

NPI: 1275959769
Provider Name (Legal Business Name): CULTIVATING CHANGE COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2014
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

392 MERROW RD STE B
TOLLAND CT
06084-3974
US

IV. Provider business mailing address

4 GLORIA LN
ELLINGTON CT
06029-2609
US

V. Phone/Fax

Practice location:
  • Phone: 860-965-2443
  • Fax:
Mailing address:
  • Phone: 860-965-2443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000964
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number002338
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6217
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number001475
License Number StateCT

VIII. Authorized Official

Name: CHRISTINE BRENTON
Title or Position: CLINICIAN/MANAGER
Credential: LPC, LADC
Phone: 860-965-2443