=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043664147
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONNECTFULNESS COUNSELING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2016
-----------------------------------------------------
Last Update Date | 04/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 521 MAIN ST
-----------------------------------------------------
City | NEW PALTZ
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12561-1609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-242-5214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 126 MAIN ST STE B
-----------------------------------------------------
City | NEW PALTZ
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12561-1525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-242-5214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LCSW
-----------------------------------------------------
Name | REBECCA WONG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 845-242-5214
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 076600
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------