=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093176356
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALING AND TRANSFORMATIVE THERAPY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2016
-----------------------------------------------------
Last Update Date | 03/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 W CENTER ST SUITE C1-2
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06040-4864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-305-8518
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 SHORES DR
-----------------------------------------------------
City | TOLLAND
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06084-2555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-305-8518
-----------------------------------------------------
Fax | 860-454-7236
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. TRACEY ANNE ROBINSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 860-305-8518
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 002003
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------