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General NPI Number Information
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NPI Number | 1457949687
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Entity Type | Organization
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Legal Business Name | NEW PROVENANCE COUNSELING CENTER, LLC
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Dates
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Enumeration Date | 01/04/2021
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Last Update Date | 02/04/2025
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Provider Practice Location Address
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Address Line | 171 MARKET SQ STE 206A
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City | NEWINGTON
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State | CT
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Zip | 06111-2930
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Country | US
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Telephone | 860-845-1503
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Fax | 860-370-4543
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Provider Business Mailing Address
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Address Line | 22 SAINT JAMES ST APT G
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City | MANCHESTER
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State | CT
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Zip | 06040-5957
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Country | US
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Telephone | 959-222-8548
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MICHELLE WORTHAM
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Credential | LCSW
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Telephone | 860-845-1503
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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