=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164261418
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPPORTIVE PSYCH SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2024
-----------------------------------------------------
Last Update Date | 05/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 266 PEARL ST APT 202
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06103-2012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-414-9225
-----------------------------------------------------
Fax | 860-413-0913
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1494
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06013-0494
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-414-9225
-----------------------------------------------------
Fax | 860-413-0913
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ELINA ALFIN
-----------------------------------------------------
Credential | PMHNP
-----------------------------------------------------
Telephone | 860-414-9225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------