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General NPI Number Information
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NPI Number | 1437569738
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Entity Type | Organization
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Legal Business Name | KALI FORTUNA LLC
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Dates
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Enumeration Date | 05/07/2014
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Last Update Date | 05/07/2014
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Provider Practice Location Address
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Address Line | 3241 MAIN ST
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City | STRATFORD
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State | CT
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Zip | 06614-4850
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Country | US
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Telephone | 203-257-2654
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Fax | 203-283-9372
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Provider Business Mailing Address
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Address Line | 3241 MAIN ST
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City | STRATFORD
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State | CT
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Zip | 06614-4850
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Country | US
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Telephone | 203-257-2654
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Fax | 203-283-9372
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Authorized Official
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Title or Position | COUNSELOR
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Name | KALI FORTUNA
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Credential | LADC, MS, NCC
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Telephone | 203-257-2654
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 1083
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License Number State | CT
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