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General NPI Number Information
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NPI Number | 1548712730
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Entity Type | Organization
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Legal Business Name | CREATIVE COACHING AND ADDICTION COUNSELING LLC
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Dates
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Enumeration Date | 11/04/2016
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Last Update Date | 11/04/2016
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Provider Practice Location Address
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Address Line | 998 FARMINGTON AVE 106A LL
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City | WEST HARTFORD
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State | CT
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Zip | 06107-2162
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Country | US
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Telephone | 602-391-3589
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Fax |
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Provider Business Mailing Address
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Address Line | 53 MANOR LN
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City | SOUTH WINDSOR
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State | CT
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Zip | 06074-3214
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Country | US
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Telephone | 602-391-3589
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Fax |
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Authorized Official
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Title or Position | THERAPIST/MANAGER
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Name | JACK RYAN
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Credential |
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Telephone | 602-391-3589
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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