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General NPI Number Information
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NPI Number | 1568890069
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Entity Type | Organization
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Legal Business Name | MGADAMS, LLC
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Dates
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Enumeration Date | 10/17/2013
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Last Update Date | 10/17/2013
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Provider Practice Location Address
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Address Line | 945 MAIN ST SUITE 211
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City | MANCHESTER
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State | CT
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Zip | 06040-6064
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Country | US
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Telephone | 860-869-2774
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1104
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City | GLASTONBURY
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State | CT
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Zip | 06033-6104
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Country | US
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Telephone | 860-869-2774
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MRS. MARTHA GAUDREAU ADAMS
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Credential | LPC
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Telephone | 860-869-2774
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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 | 2375
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License Number State | CT
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