Healthcare Provider Details

I. General information

NPI: 1700998341
Provider Name (Legal Business Name): MARK J MEOLA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 GROVE ST
TORRINGTON CT
06790-5047
US

IV. Provider business mailing address

132 GROVE ST
TORRINGTON CT
06790-5047
US

V. Phone/Fax

Practice location:
  • Phone: 860-482-5558
  • Fax: 860-489-2984
Mailing address:
  • Phone: 860-482-5558
  • Fax: 860-489-2984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number004480
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: