Healthcare Provider Details

I. General information

NPI: 1861532152
Provider Name (Legal Business Name): ROBIN ROSEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 02/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 MERROW RD STE D
TOLLAND CT
06084-3957
US

IV. Provider business mailing address

384 MERROW RD STE D
TOLLAND CT
06084-3957
US

V. Phone/Fax

Practice location:
  • Phone: 860-875-2578
  • Fax: 860-875-9963
Mailing address:
  • Phone: 860-875-2578
  • Fax: 860-875-9963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000365
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number004864
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number000631
License Number StateCT

VIII. Authorized Official

Name: MS. ROBIN G. ROSEN
Title or Position: OWNER
Credential: LADC
Phone: 860-875-2578