=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811686439
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIDE & JOY COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2023
-----------------------------------------------------
Last Update Date | 05/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12 GLENVILLE ST UNIT 110
-----------------------------------------------------
City | GREENWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06831-3688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-295-4124
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 GLENVILLE ST UNIT 110
-----------------------------------------------------
City | GREENWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06831-3688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICIAN/OWNER
-----------------------------------------------------
Name | KALAN ELIZABETH ROSS
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 203-295-4124
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------