=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932870391
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELL BALANCED COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2021
-----------------------------------------------------
Last Update Date | 09/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 HARVARD ST
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06106-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-778-0363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 HARVARD ST
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06106-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-778-0363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | JASMINE FENTON
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 860-778-0363
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------