Healthcare Provider Details

I. General information

NPI: 1790610681
Provider Name (Legal Business Name): THERESA NAOMIMA SIMBOLON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CHURCH ST
WALLINGFORD CT
06492
US

IV. Provider business mailing address

301 WINCHESTER AVE APT 104
NEW HAVEN CT
06511-8054
US

V. Phone/Fax

Practice location:
  • Phone: 203-314-0940
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9825
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: