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General NPI Number Information
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NPI Number | 1124524798
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Entity Type | Organization
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Legal Business Name | IMAGE OF LIGHT MENTAL HEALTH SERVICES, LLC
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Dates
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Enumeration Date | 04/03/2018
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Last Update Date | 07/09/2018
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Provider Practice Location Address
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Address Line | 45 S MAIN ST STE 70
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City | WEST HARTFORD
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State | CT
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Zip | 06107
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Country | US
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Telephone | 860-299-6677
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Fax |
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Provider Business Mailing Address
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Address Line | 53 BURNWOOD DR
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City | BLOOMFIELD
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State | CT
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Zip | 06002-2235
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Country | US
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Telephone | 860-299-6677
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MIRIAM HAYNES
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Credential | APRN
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Telephone | 860-299-6677
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State | CT
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