MEDICARE: FARMINGTON VALLEY INTEGRATIVE THERAPY, 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	103TC0700X	Clinical Psychologist	003176	CT

General Provider Information

NPI Number	:	1932561222
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FARMINGTON VALLEY INTEGRATIVE THERAPY, LLC

Provider Business Mailing Address
First Line	:	35 TOWER LN STE 104
Second Line	:
City	:	AVON
State	:	CT
Zip	:	06001-4237
Country	:	US
Telephone Number	:	860-751-9257
Fax Number	:	860-516-1170

Provider Business Practice Location Address
First Line	:	35 TOWER LN STE 104
Second Line	:
City	:	AVON
State	:	CT
Zip	:	06001-4237
Country	:	US
Telephone Number	:	860-751-9257
Fax Number	:	860-516-1170

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST
Name	:	DR. VIRGINIA DALTON TAYLOR
Credential	:	PHD
Telephone Number	:	860-751-9257

Provider Enumeration Date	:	03/24/2016
Last Update Date	:	03/24/2016

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