=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912642877
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BURCU ALTINTAS LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2022
-----------------------------------------------------
Last Update Date | 05/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 670 MAIN ST S STE B2
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06798-3738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-263-3175
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 90 UNION AVE
-----------------------------------------------------
City | WEST HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06516-5048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-942-2660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 5529
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------