MEDICARE: RIGHT TRACK PSYCHOTHERAPY 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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1083368690
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIGHT TRACK PSYCHOTHERAPY LLC

Provider Business Mailing Address
First Line	:	925 SULLIVAN AVE STE 2
Second Line	:
City	:	SOUTH WINDSOR
State	:	CT
Zip	:	06074-2080
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	925 SULLIVAN AVE STE 2
Second Line	:
City	:	SOUTH WINDSOR
State	:	CT
Zip	:	06074-2080
Country	:	US
Telephone Number	:	860-432-7771
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ALAN HARRIS LAKE
Credential	:	LCSW
Telephone Number	:	860-402-4402

Provider Enumeration Date	:	02/11/2022
Last Update Date	:	02/11/2022

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