MEDICARE: JODY MICHAEL KOVAL LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	002238	CT

General Provider Information

NPI Number	:	1023361482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JODY MICHAEL KOVAL LPC

Provider Business Mailing Address
First Line	:	1199 WHITNEY AVE
Second Line	:	#513
City	:	HAMDEN
State	:	CT
Zip	:	06517-2872
Country	:	US
Telephone Number	:	203-918-8025
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 KINGS HIGHWAY EAST
Second Line	:	SUITE 108, E12
City	:	FAIRFIELD
State	:	CT
Zip	:	06825-4859
Country	:	US
Telephone Number	:	203-918-8025
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2012
Last Update Date	:	10/23/2012

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