=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194130112
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEARNING TO LIVE LIFE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2014
-----------------------------------------------------
Last Update Date | 06/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 182 GRAND ST SUITE 420-422
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06702-1914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-528-3054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 182 GRAND ST SUITE 420-422
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06702-1914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-528-3054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | CLARISSA GARNETT
-----------------------------------------------------
Credential | LADC
-----------------------------------------------------
Telephone | 860-883-7062
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 000695
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------