=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790345700
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALING HEARTS THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2019
-----------------------------------------------------
Last Update Date | 06/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 66 CEDAR ST STE 201
-----------------------------------------------------
City | NEWINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06111-2646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-761-5224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 123 ADELAIDE ST FL 2
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06114-1875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-761-5224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MS. NICKESHA YANQUIE COLEY
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 860-761-5224
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------