=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861256141
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRATEFUL GUIDANCE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2024
-----------------------------------------------------
Last Update Date | 02/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 752 MIDDLETOWN RD
-----------------------------------------------------
City | COLCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06415-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-334-2088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 752 MIDDLETOWN RD
-----------------------------------------------------
City | COLCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06415-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-334-2088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MISS ANDREA HYATT SHAKER
-----------------------------------------------------
Credential | MA, LPC
-----------------------------------------------------
Telephone | 860-334-2088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------