Provider Demographics
NPI:1023361482
Name:KOVAL, JODY MICHAEL (LPC)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:MICHAEL
Last Name:KOVAL
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1199 WHITNEY AVE
Mailing Address - Street 2:#513
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06517-2872
Mailing Address - Country:US
Mailing Address - Phone:203-918-8025
Mailing Address - Fax:
Practice Address - Street 1:501 KINGS HIGHWAY EAST
Practice Address - Street 2:SUITE 108, E12
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-4859
Practice Address - Country:US
Practice Address - Phone:203-918-8025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002238101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional