Healthcare Provider Details

I. General information

NPI: 1326779554
Provider Name (Legal Business Name): MICHAEL FAIELLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 06/20/2022
Certification Date: 06/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 MAIN ST S STE B2
WOODBURY CT
06798-3738
US

IV. Provider business mailing address

81 HOWARD AVE
ANSONIA CT
06401-2209
US

V. Phone/Fax

Practice location:
  • Phone: 203-263-3175
  • Fax:
Mailing address:
  • Phone: 203-906-7471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4620
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: