=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235620154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMANTHA BACHMAN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2018
-----------------------------------------------------
Last Update Date | 05/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 DEPOT PL FL 1
-----------------------------------------------------
City | BETHEL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06801-2540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-313-1541
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14 DEPOT PL FL 1
-----------------------------------------------------
City | BETHEL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06801-2540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. SAMANTHA BACHMAN
-----------------------------------------------------
Credential | LLC
-----------------------------------------------------
Telephone | 203-313-1541
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 003406
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------