=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417554866
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEART AND CROWN HEALING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2020
-----------------------------------------------------
Last Update Date | 10/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 609 W JOHNSON AVE
-----------------------------------------------------
City | CHESHIRE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06410-4505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-709-1866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38 FARVIEW DR
-----------------------------------------------------
City | CHESHIRE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06410-1308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-709-1866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MISS ALYSIA CHERIE SKLENARIK
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 203-709-1866
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------