=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952199127
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIA DATES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2025
-----------------------------------------------------
Last Update Date | 12/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3300 MAIN ST
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06614-4819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-378-4514
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 510 MIRIAM CT
-----------------------------------------------------
City | GRAY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37615-2383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------