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General NPI Number Information
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NPI Number | 1083938872
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Entity Type | Organization
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Legal Business Name | OLD LYME COUNSELING, LLC
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Dates
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Enumeration Date | 03/23/2010
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Last Update Date | 09/27/2010
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Provider Practice Location Address
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Address Line | 4 DAVIS RD W SUITE 6
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City | OLD LYME
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State | CT
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Zip | 06371-4408
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Country | US
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Telephone | 860-617-4082
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Fax |
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Provider Business Mailing Address
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Address Line | 19 BEECHWOOD BLVD
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City | NORWICH
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State | CT
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Zip | 06360-1405
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Country | US
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Telephone | 860-617-4082
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Fax |
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Authorized Official
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Title or Position | PART OWNER
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Name | MRS. HEATHER BONITZ MOORE
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Credential | MS, ATR-BC, LPC
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Telephone | 860-617-4082
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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