=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871038737
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BREHAN COSGROVE, LMFT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2017
-----------------------------------------------------
Last Update Date | 01/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45 S MAIN ST SUITE 300
-----------------------------------------------------
City | WEST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06107-2441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-840-7491
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37 BELCREST RD
-----------------------------------------------------
City | WEST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06107-3302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MARRIAGE AND FAMILY THERAPIST
-----------------------------------------------------
Name | BREHAN COSGROVE
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 860-805-1430
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 001820
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------