MEDICARE: DUNGARVIN CONNECTICUT, 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	101YP2500X	Professional Counselor	000421	CT

General Provider Information

NPI Number	:	1790157899
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DUNGARVIN CONNECTICUT, LLC

Provider Business Mailing Address
First Line	:	1444 NORTHLAND DR STE 200
Second Line	:
City	:	MENDOTA HEIGHTS
State	:	MN
Zip	:	55120-1032
Country	:	US
Telephone Number	:	651-699-0206
Fax Number	:	651-699-0799

Provider Business Practice Location Address
First Line	:	19 KENSINGTON LANE
Second Line	:
City	:	ROCKY HILLS
State	:	CT
Zip	:	06067-3526
Country	:	US
Telephone Number	:	860-257-1556
Fax Number	:	860-257-3024

Authorized Official
Title or Position	:	CEO
Name	:	LORI KRESS
Credential	:
Telephone Number	:	651-699-0206

Provider Enumeration Date	:	10/28/2015
Last Update Date	:	04/27/2023

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