Healthcare Provider Details

I. General information

NPI: 1396252276
Provider Name (Legal Business Name): MARRIOTT LPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2018
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1447 NEW LITCHFIELD ST
TORRINGTON CT
06790-6021
US

IV. Provider business mailing address

1447 NEW LITCHFIELD ST
TORRINGTON CT
06790-6021
US

V. Phone/Fax

Practice location:
  • Phone: 203-551-4947
  • Fax: 203-549-0503
Mailing address:
  • Phone: 203-551-4947
  • Fax: 203-549-0503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateCT

VIII. Authorized Official

Name: MS. OLUWATOSIN MARRIOTT
Title or Position: OWNER
Credential: LPC
Phone: 203-551-4947