Healthcare Provider Details

I. General information

NPI: 1215717962
Provider Name (Legal Business Name): GREY STREET COUNSELING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 WOLCOTT RD STE D
WOLCOTT CT
06716-2462
US

IV. Provider business mailing address

504 WOLCOTT RD STE D
WOLCOTT CT
06716-2462
US

V. Phone/Fax

Practice location:
  • Phone: 203-441-7557
  • Fax:
Mailing address:
  • Phone: 203-441-7557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: DANA WALLACE
Title or Position: OWNER
Credential: LPC
Phone: 203-441-7557