Healthcare Provider Details

I. General information

NPI: 1487116521
Provider Name (Legal Business Name): VINCENT A HOLLISTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 MECHANIC ST
WINDSOR CT
06095-2545
US

IV. Provider business mailing address

99 HIGHLAND VIEW DR
SOMERS CT
06071-1557
US

V. Phone/Fax

Practice location:
  • Phone: 860-716-5998
  • Fax:
Mailing address:
  • Phone: 860-716-5998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. VINCENT A HOLLISTER
Title or Position: OWNER
Credential: LCSW- CT, LICSW-MA
Phone: 860-716-5998