=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407227812
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL FAMILY THERAPY-LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2015
-----------------------------------------------------
Last Update Date | 10/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 222 MCKEE ST
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06040-4800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-584-3727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 222 MCKEE ST
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06040-4800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-584-3727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR/OWNER
-----------------------------------------------------
Name | CHRISTOPHER ROBERT DUMAS
-----------------------------------------------------
Credential | L.M.F.T.
-----------------------------------------------------
Telephone | 860-281-9588
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 000873
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------