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General NPI Number Information
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NPI Number | 1760856181
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Entity Type | Organization
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Legal Business Name | KMG THERAPY AND CONSULTING LLC
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Dates
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Enumeration Date | 11/23/2015
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Last Update Date | 11/23/2015
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Provider Practice Location Address
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Address Line | 481 GOLD STAR HWY SUITE 301
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City | GROTON
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State | CT
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Zip | 06340-6702
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Country | US
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Telephone | 860-917-1779
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Fax | 860-447-8122
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Provider Business Mailing Address
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Address Line | 1075 E LAKE RD
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City | OAKDALE
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State | CT
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Zip | 06370-1818
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Country | US
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Telephone | 860-917-1779
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Fax | 860-447-8122
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Authorized Official
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Title or Position | MEMBER
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Name | MARIA M GALLAGHER
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Credential | LCSW
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Telephone | 860-917-1779
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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 | 8823
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License Number State | CT
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