MEDICARE: JONATHAN STERN, M.S., L.P.C., L.A.D.C., COUNSELING AND PSYCHOTHERAPY S

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	251S00000X	Community/Behavioral Health Agency	000823	CT
2	251S00000X	Community/Behavioral Health Agency	001882	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12094074	OTHER	CT	CAQH
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1018781	OTHER	CT	CIGNA PROVIDER ID

General Provider Information

NPI Number	:	1316289531
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JONATHAN STERN, M.S., L.P.C., L.A.D.C., COUNSELING AND PSYCHOTHERAPY S

Provider Business Mailing Address
First Line	:	2911 DIXWELL AVE
Second Line	:	SUITE B-5
City	:	HAMDEN
State	:	CT
Zip	:	06518-3195
Country	:	US
Telephone Number	:	203-916-5496
Fax Number	:	203-265-1216

Provider Business Practice Location Address
First Line	:	2911 DIXWELL AVE
Second Line	:	SUITE B-5
City	:	HAMDEN
State	:	CT
Zip	:	06518-3195
Country	:	US
Telephone Number	:	203-916-5496
Fax Number	:	203-265-1216

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JONATHAN DAVID STERN
Credential	:	L.P.C., L.A.D.C.
Telephone Number	:	203-213-9987

Provider Enumeration Date	:	03/26/2013
Last Update Date	:	03/26/2013

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