=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881265734
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINE BOUEY LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2021
-----------------------------------------------------
Last Update Date | 07/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 PEARL ST FL 14
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06103-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-301-6823
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 208 RISING TRAIL DR
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06457-1663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-301-6825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 004565
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------