MEDICARE: EXPRESS YOURSELF CT, LLC

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	251B00000X	Case Management Agency	006229	CT

General Provider Information

NPI Number	:	1033472162
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXPRESS YOURSELF CT, LLC

Provider Business Mailing Address
First Line	:	82 BURNSIDE AVE
Second Line	:	REAR
City	:	EAST HARTFORD
State	:	CT
Zip	:	06108-3413
Country	:	US
Telephone Number	:	203-660-8016
Fax Number	:	860-578-9007

Provider Business Practice Location Address
First Line	:	82 BURNSIDE AVE
Second Line	:	REAR
City	:	EAST HARTFORD
State	:	CT
Zip	:	06108-3413
Country	:	US
Telephone Number	:	203-660-8016
Fax Number	:	860-578-9007

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MS. SYLVIA DENISE REID
Credential	:	ESQ
Telephone Number	:	203-660-8016

Provider Enumeration Date	:	06/22/2012
Last Update Date	:	06/22/2012

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