=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841761087
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLLABORATIVE COUNSELING CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2018
-----------------------------------------------------
Last Update Date | 12/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 175 MAIN ST FL 2
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06106-1818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-965-9757
-----------------------------------------------------
Fax | 860-246-0495
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 175 MAIN ST FL 2
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06106-1818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-965-9757
-----------------------------------------------------
Fax | 860-246-0495
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LCSW
-----------------------------------------------------
Name | MS. ALICIA THOMPKINS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 860-965-9757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------