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General NPI Number Information
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NPI Number | 1740648047
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Entity Type | Organization
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Legal Business Name | INNER WISDOM PSYCHOTHERAPY
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Dates
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Enumeration Date | 02/02/2016
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Last Update Date | 02/02/2016
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Provider Practice Location Address
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Address Line | 122A NAUBUC AVE SUITE 210
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City | GLASTONBURY
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State | CT
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Zip | 06033-4246
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Country | US
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Telephone | 860-218-0948
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Fax |
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Provider Business Mailing Address
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Address Line | 122A NAUBUC AVE SUITE 210
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City | GLASTONBURY
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State | CT
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Zip | 06033-4246
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Country | US
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Telephone | 860-218-0948
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Fax |
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Authorized Official
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Title or Position | COUNSELOR
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Name | PAMELA MULREADY
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Credential | LPC, LADC
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Telephone | 860-218-0948
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 1928
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License Number State | CT
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