=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851640163
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ETHERAPY OF CONNECTICUT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2012
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1062 BARNES RD STE 106
-----------------------------------------------------
City | WALLINGFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06492-6012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-882-3268
-----------------------------------------------------
Fax | 203-265-0165
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 126 DAMASCUS RD
-----------------------------------------------------
City | BRANFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06405-3961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-882-3268
-----------------------------------------------------
Fax | 203-265-0165
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER & PROVIDER
-----------------------------------------------------
Name | JUSTIN ANDREW ROGALA
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 203-308-8739
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 006512
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 006512
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------