Healthcare Provider Details

I. General information

NPI: 1134658396
Provider Name (Legal Business Name): CHARTER OAK THERAPEUTIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 06/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 WOLCOTT RD STE 2
WOLCOTT CT
06716-2641
US

IV. Provider business mailing address

246 WOLCOTT RD STE 2
WOLCOTT CT
06716-2641
US

V. Phone/Fax

Practice location:
  • Phone: 860-863-6342
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9523
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1634
License Number StateCT

VIII. Authorized Official

Name: SHARON SANZARI
Title or Position: BILLER
Credential:
Phone: 203-371-7311