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General NPI Number Information
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NPI Number | 1538582739
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Entity Type | Organization
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Legal Business Name | EASTERN SERVICES & CAMP SIMON LLC
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Dates
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Enumeration Date | 01/24/2014
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Last Update Date | 02/11/2020
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Provider Practice Location Address
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Address Line | 82 MAIN ST
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City | WINDSOR LOCKS
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State | CT
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Zip | 06096-2325
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Country | US
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Telephone | 860-254-5127
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Fax | 860-310-4235
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Provider Business Mailing Address
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Address Line | 115 BRIDGE ST SUITE C
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City | EAST WINDSOR
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State | CT
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Zip | 06088-9547
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Country | US
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Telephone | 860-254-5127
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Fax | 860-254-5254
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Authorized Official
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Title or Position | CLINICAL DIRECTOR/OWNER
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Name | MALY PHIMVONGSA
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Credential |
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Telephone | 860-254-5127
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health 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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 002227
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License Number State | CT
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 001470
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License Number State | CT
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