Healthcare Provider Details

I. General information

NPI: 1255193983
Provider Name (Legal Business Name): MARYBETH TEDESCO LPC, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 MIGEON AVE
TORRINGTON CT
06790-4816
US

IV. Provider business mailing address

127 MIGEON AVE
TORRINGTON CT
06790-4816
US

V. Phone/Fax

Practice location:
  • Phone: 860-496-2105
  • Fax:
Mailing address:
  • Phone: 860-496-2105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9869
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1540
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: