=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720781420
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEURODIVERSE HEART, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2023
-----------------------------------------------------
Last Update Date | 03/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 BRACE RD
-----------------------------------------------------
City | WEST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06107-1825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-479-1183
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27 GERTHMERE DR
-----------------------------------------------------
City | WEST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06110-1619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-965-9948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CLINICIAN
-----------------------------------------------------
Name | KATHLEEN W JOHNDROW
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 860-479-1183
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------