Provider Demographics
NPI:1083938872
Name:OLD LYME COUNSELING, LLC
Entity Type:Organization
Organization Name:OLD LYME COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:BONITZ MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, ATR-BC, LPC
Authorized Official - Phone:860-617-4082
Mailing Address - Street 1:19 BEECHWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-1405
Mailing Address - Country:US
Mailing Address - Phone:860-617-4082
Mailing Address - Fax:
Practice Address - Street 1:4 DAVIS RD W
Practice Address - Street 2:SUITE 6
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371-4408
Practice Address - Country:US
Practice Address - Phone:860-617-4082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health