Healthcare Provider Details

I. General information

NPI: 1518443027
Provider Name (Legal Business Name): PROFESSIONAL INSTITUTE FOR CLINICAL SERVICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 BLOOMFIELD AVE STE 306
WINDSOR CT
06095-2700
US

IV. Provider business mailing address

114 INDIAN HILL RD
WINDSOR CT
06095-1453
US

V. Phone/Fax

Practice location:
  • Phone: 860-539-5995
  • Fax:
Mailing address:
  • Phone: 860-539-5995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number009351
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. TRUDY TAMARA PEARSON
Title or Position: CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 860-539-5995