=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548079692
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUNAR PATH COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2025
-----------------------------------------------------
Last Update Date | 01/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 175 MILL POND RD UNIT 404
-----------------------------------------------------
City | HAMDEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06514-1731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-335-2756
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 175 MILL POND RD UNIT 404
-----------------------------------------------------
City | HAMDEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06514-1731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-335-2756
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICIAN
-----------------------------------------------------
Name | CHRISTIE LEE BEAULIEU
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 860-335-2756
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------