=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851844534
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAFE JOURNEY COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2016
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 76 WESTBURY PARK RD
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06795-2779
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-305-6390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 254 TUTTLE RD
-----------------------------------------------------
City | SOUTHBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06488-3904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-305-6390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICIAN
-----------------------------------------------------
Name | NICOLE BROOKE GILMAN-YAP
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 203-305-6390
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 002967
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------