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General NPI Number Information
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NPI Number | 1386064582
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Entity Type | Individual
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Provider Name | MARY LAURA MCGANNON PH.D
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Gender | Female
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Dates
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Enumeration Date | 04/27/2014
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Last Update Date | 04/27/2014
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Provider Practice Location Address
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Address Line | 29 MAIN ST
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City | ESSEX
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State | CT
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Zip | 06426-1134
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Country | US
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Telephone | 860-639-1276
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Fax |
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Provider Business Mailing Address
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Address Line | 390 DARLING RD
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City | SALEM
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State | CT
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Zip | 06420-3913
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Country | US
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Telephone | 860-639-1276
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 000176
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License Number State | CT
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