=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164979423
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLYN R GUMBRECHT LMFT, MALS, B.S.ED
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2016
-----------------------------------------------------
Last Update Date | 09/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1163 BOSTON POST RD
-----------------------------------------------------
City | WESTBROOK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06498-1947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-399-2939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 RIVER EDGE FARMS RD
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06443-2756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-245-0424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 001824
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------