=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437769122
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KLINGBERG FAMILY CENTERS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2020
-----------------------------------------------------
Last Update Date | 08/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 157 CHARTER OAK AVE
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06106-1913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-515-2383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 144 GRIFFIN RD
-----------------------------------------------------
City | SOUTH WINDSOR
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06074-1216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-729-0771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PER DIEM OUTPATIENT THERAPIST
-----------------------------------------------------
Name | MRS. PAULA ANDREA BERSON
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 860-515-2383
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------