=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538651179
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WISDOM WITHIN COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2018
-----------------------------------------------------
Last Update Date | 05/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 461 MAIN ST
-----------------------------------------------------
City | NIANTIC
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06357-3103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-984-1205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 461 MAIN ST
-----------------------------------------------------
City | NIANTIC
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06357-3103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-984-1205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MARRIAGE AND FAMILY THERAPIST
-----------------------------------------------------
Name | KATHERINE L ZISKIND
-----------------------------------------------------
Credential | MFT, RTY500,
-----------------------------------------------------
Telephone | 860-984-1205
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 001996
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------