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General NPI Number Information
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NPI Number | 1023425964
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Entity Type | Organization
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Legal Business Name | INNER PEACE PSYCHOTHERAPY, LLC
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Dates
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Enumeration Date | 07/11/2014
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Last Update Date | 07/11/2014
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Provider Practice Location Address
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Address Line | 9A PASCO DR
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City | EAST WINDSOR
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State | CT
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Zip | 06088-1700
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Country | US
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Telephone | 860-977-6272
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Fax |
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Provider Business Mailing Address
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Address Line | 63 FOSTER LN
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City | WINDSOR
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State | CT
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Zip | 06095-2014
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Country | US
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Telephone | 860-977-6272
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Fax |
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Authorized Official
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Title or Position | PSYCHOTHERAPIST LPC
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Name | MRS. KELLY MARIE PORTER
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Credential |
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Telephone | 860-977-6272
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 2570
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License Number State | CT
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