Healthcare Provider Details

I. General information

NPI: 1164979423
Provider Name (Legal Business Name): CAROLYN R GUMBRECHT LMFT, MALS, B.S.ED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2016
Last Update Date: 09/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1163 BOSTON POST RD
WESTBROOK CT
06498-1947
US

IV. Provider business mailing address

40 RIVER EDGE FARMS RD
MADISON CT
06443-2756
US

V. Phone/Fax

Practice location:
  • Phone: 860-399-2939
  • Fax:
Mailing address:
  • Phone: 203-245-0424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number001824
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: