=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013583640
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHADE OF LIGHT COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2021
-----------------------------------------------------
Last Update Date | 06/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 92 BLUEBERRY KNLS
-----------------------------------------------------
City | MIDDLEBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06762-1716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-768-4427
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 92 BLUEBERRY KNLS
-----------------------------------------------------
City | MIDDLEBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06762-1716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-768-4427
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | IOLANDA MARUCCI
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 203-768-4427
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------