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General NPI Number Information
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NPI Number | 1548760267
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Entity Type | Organization
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Legal Business Name | EMBRACE LIFE THERAPEUTIC SERVICES, LLC
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Dates
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Enumeration Date | 02/19/2018
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Last Update Date | 02/19/2018
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Provider Practice Location Address
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Address Line | 81 W MAIN ST STE B
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City | NEW BRITAIN
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State | CT
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Zip | 06051-4221
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Country | US
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Telephone | 860-833-1919
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Fax |
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Provider Business Mailing Address
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Address Line | 315 HILLSIDE AVE
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City | HARTFORD
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State | CT
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Zip | 06106-3821
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Country | US
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Telephone | 860-833-1919
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Fax |
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Authorized Official
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Title or Position | LICENSE PROFESSIONAL COUNSELOR
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Name | MARY JANE BEZARES
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Credential | LPC, NCC
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Telephone | 860-833-1919
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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 | 3283
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License Number State | CT
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