=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235658311
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PIECED TOGETHER THERAPEUTIC ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 764 COLONEL LEDYARD HWY UNIT 204
-----------------------------------------------------
City | LEDYARD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06339-7012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-961-2995
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 764 COLONEL LEDYARD HWY UNIT 204
-----------------------------------------------------
City | LEDYARD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06339-7012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-961-2995
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICIAN
-----------------------------------------------------
Name | JENNIFER THOMASSON
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 860-961-2995
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 3263
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------