=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235014051
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL CT THERAPEUTIC SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2025
-----------------------------------------------------
Last Update Date | 08/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 DELAHUNTY DR
-----------------------------------------------------
City | SOUTHINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06489-3667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-385-1620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2389 MAIN ST
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-4617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-385-1620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOIGST
-----------------------------------------------------
Name | DR. ALICIA JEAN LAROSE
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 860-385-1620
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------