=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700975810
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT I GOLDSMITH M.S., LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 MAIN ST
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06042-3581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-646-9668
-----------------------------------------------------
Fax | 860-643-4074
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 MARLBORO GLADE
-----------------------------------------------------
City | TOLLAND
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06084-3554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-875-1418
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 000820
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------