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General NPI Number Information
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NPI Number | 1275279697
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Entity Type | Organization
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Legal Business Name | SOUTHWINDSORPSYCHOTHERAPY
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Dates
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Enumeration Date | 05/09/2022
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Last Update Date | 05/09/2022
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Provider Practice Location Address
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Address Line | 1169 ELLINGTON RD
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City | SOUTH WINDSOR
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State | CT
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Zip | 06074-3515
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Country | US
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Telephone | 860-978-5916
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Fax |
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Provider Business Mailing Address
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Address Line | 512 MAIN ST
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City | NEWINGTON
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State | CT
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Zip | 06111-2413
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Country | US
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Telephone | 860-978-5916
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Fax |
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Authorized Official
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Title or Position | LICENSED CLINICAL SOCIAL WORKER
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Name | MR. TIMOTHY J JESKI
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Credential | LCSW
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Telephone | 860-324-2840
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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