=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952894289
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHY OUTLOOKS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2018
-----------------------------------------------------
Last Update Date | 06/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 43 SHERMAN HILL RD
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06798-3651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-509-8244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 42 ARVIDA RD
-----------------------------------------------------
City | WOLCOTT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06716-2766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-509-8244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | SUZANNE DEROSA
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 203-509-8244
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 001350
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------