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General NPI Number Information
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NPI Number | 1467010116
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Entity Type | Organization
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Legal Business Name | PRIMAL MENTAL AND PHYSICAL HEALTH
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Dates
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Enumeration Date | 05/29/2019
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Last Update Date | 05/29/2019
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Provider Practice Location Address
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Address Line | 900 MAIN ST
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City | OAKVILLE
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State | CT
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Zip | 06779-1999
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Country | US
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Telephone | 203-456-7335
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Fax |
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Provider Business Mailing Address
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Address Line | 54 BELLEVUE TER
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City | SEYMOUR
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State | CT
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Zip | 06483-3202
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | SHIRLEY GEE
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Credential |
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Telephone | 203-456-7335
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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Taxonomy #2
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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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