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General NPI Number Information
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NPI Number | 1710228036
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Entity Type | Organization
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Legal Business Name | INNER PEACE CT
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Dates
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Enumeration Date | 03/12/2013
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Last Update Date | 03/12/2013
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Provider Practice Location Address
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Address Line | 83 BOSTON POST RD
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City | WATERFORD
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State | CT
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Zip | 06385-2423
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Country | US
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Telephone | 860-917-0790
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Fax | 860-443-0748
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Provider Business Mailing Address
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Address Line | 83 BOSTON POST RD
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City | WATERFORD
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State | CT
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Zip | 06385-2423
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Country | US
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Telephone | 860-917-0790
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Fax | 860-443-0748
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Authorized Official
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Title or Position | CLINICAL PROGRAM DIRECTOR
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Name | JENNIFER ANN CLARK
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Credential | LCSW
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Telephone | 860-917-0790
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 006060
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License Number State | CT
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