=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679417877
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMARA KESHIA CHUCHRO MA,LPCA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2026
-----------------------------------------------------
Last Update Date | 04/17/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 MAIN ST STE B214
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06032-2985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-941-5255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43 BANTLE RD
-----------------------------------------------------
City | EAST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06118-2833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-655-7707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 9466
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------