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General NPI Number Information
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NPI Number | 1215413505
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Entity Type | Organization
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Legal Business Name | MIA VITA COUNSELING LLC
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Dates
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Enumeration Date | 07/19/2018
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Last Update Date | 07/19/2018
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Provider Practice Location Address
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Address Line | 425 DIXWELL AVE
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City | NEW HAVEN
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State | CT
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Zip | 06511-1771
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Country | US
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Telephone | 203-489-6524
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Fax |
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Provider Business Mailing Address
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Address Line | 112 GREAT NECK RD
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City | WATERFORD
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State | CT
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Zip | 06385-3504
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Country | US
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Telephone | 860-857-4769
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. MALLORY R DEVONA
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Credential | LPC
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Telephone | 860-857-4769
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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