=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992393110
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRENDA'S WAY COUNSELING SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2021
-----------------------------------------------------
Last Update Date | 01/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 157 CHURCH ST FL 19
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06510-2100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-368-8538
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 192 RYAN AVE
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06615-7413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-675-4815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. DAWN W GRANT-LOCKLEY
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 203-675-4815
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------