=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831657048
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAITHFULLY GROWING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2019
-----------------------------------------------------
Last Update Date | 04/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 647 CALIFORNIA ST
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06614-4908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-727-2051
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 647 CALIFORNIA ST
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06614-4908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-727-2051
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NIA DANIELLE DENARD-WALKER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 203-727-2051
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------