Healthcare Provider Details

I. General information

NPI: 1285040675
Provider Name (Legal Business Name): AUTHENTIC RECOVERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 01/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CARRIAGE PL SUITE 4
WATERBURY CT
06702-2108
US

IV. Provider business mailing address

37 SAW MILL RD
LITCHFIELD CT
06759-2001
US

V. Phone/Fax

Practice location:
  • Phone: 860-805-2267
  • Fax:
Mailing address:
  • Phone: 860-805-2267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN W SIMONCELLI
Title or Position: EXECUTIVE DIRECTOR
Credential: L.A.D.C., M.S.W.
Phone: 860-805-2267