=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588906184
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JILL BROMLEY M.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2013
-----------------------------------------------------
Last Update Date | 11/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3-5 EAST HAMPTON RD UNIT 5, MARLBOROUGH TAVERN GREEN
-----------------------------------------------------
City | MARLBOROUGH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06447-1527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-778-0560
-----------------------------------------------------
Fax | 860-365-5318
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 146 CHENEY RD
-----------------------------------------------------
City | MARLBOROUGH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06447-1332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-705-1730
-----------------------------------------------------
Fax | 860-365-5318
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 002417
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------