=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639627508
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JASON T CERRO LPC INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2016
-----------------------------------------------------
Last Update Date | 09/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3175 GOLD STAR HWY UNIT 104, G3
-----------------------------------------------------
City | MYSTIC
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06355-1200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-524-5938
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14 FIELDSTONE WAY
-----------------------------------------------------
City | WESTERLY
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02891-2697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-524-5938
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JASON T CERRO
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 401-524-5938
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 002261
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------