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General NPI Number Information
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NPI Number | 1609665520
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Entity Type | Organization
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Legal Business Name | FIRST LIGHT COLLECTIVE INCORPORATED
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Dates
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Enumeration Date | 05/06/2025
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Last Update Date | 05/06/2025
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Provider Practice Location Address
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Address Line | 30 CLINTON ST
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City | MANCHESTER
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State | CT
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Zip | 06040-6132
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Country | US
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Telephone | 860-486-3592
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Fax |
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Provider Business Mailing Address
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Address Line | 341 E CENTER ST # 132
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City | MANCHESTER
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State | CT
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Zip | 06040-4484
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | AZARIA DRAKEFORD
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Credential | LPC,LMHC
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Telephone | 860-682-3358
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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