=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811426562
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELEONORA COREY COUNSELING SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2017
-----------------------------------------------------
Last Update Date | 06/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 91 BELLEVUE AVE
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06010-5817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-736-7397
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 115 MOUNTAIN VIEW AVE
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06010-4896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-302-7918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | MRS. ELEONORA COREY
-----------------------------------------------------
Credential | MS, LPC
-----------------------------------------------------
Telephone | 860-302-7918
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 002738
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------