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General NPI Number Information
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NPI Number | 1801147400
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Entity Type | Organization
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Legal Business Name | SCOTT L GOURSON LLC
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Dates
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Enumeration Date | 09/24/2012
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Last Update Date | 09/24/2012
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Provider Practice Location Address
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Address Line | 111 MAIN ST
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City | COLLINSVILLE
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State | CT
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Zip | 06019-3182
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Country | US
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Telephone | 860-693-4201
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Fax | 860-693-4991
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Provider Business Mailing Address
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Address Line | 111 MAIN ST
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City | COLLINSVILLE
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State | CT
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Zip | 06019-3182
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Country | US
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Telephone | 860-693-4201
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Fax | 860-693-4991
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DR. SCOTT L GOURSON
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Credential | PHD, LPC, LDAC, CCDP
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Telephone | 860-693-4201
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 001858
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License Number State | CT
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