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General NPI Number Information
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NPI Number | 1649791310
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Entity Type | Individual
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Provider Name | IAN ZETTERVALL LPC, LADC
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Gender | Male
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Dates
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Enumeration Date | 07/03/2017
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Last Update Date | 04/01/2022
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Provider Practice Location Address
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Address Line | 61 BRADLEY ST
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City | BRISTOL
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State | CT
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Zip | 06010-5103
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Country | US
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Telephone | 860-863-1937
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Fax |
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Provider Business Mailing Address
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Address Line | 135 BREWSTER RD
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City | BRISTOL
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State | CT
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Zip | 06010-5212
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Country | US
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Telephone | 860-630-0820
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 001211
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 46.003558
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License Number State | CT
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