=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316791635
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LILIANA JIMENEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2024
-----------------------------------------------------
Last Update Date | 04/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 N MAIN ST
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06010-4926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-506-7991
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 513 EAST ST
-----------------------------------------------------
City | NEW BRITAIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06051-4808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 959-255-7912
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 8516
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------