Provider Demographics
NPI:1346772167
Name:JOLOLIAN, LORY SETA (LPC)
Entity Type:Individual
Prefix:MISS
First Name:LORY
Middle Name:SETA
Last Name:JOLOLIAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:400 COLUMBUS AVENUE
Mailing Address - Street 2:CREDENTIALING SPECIALIST
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1233
Mailing Address - Country:US
Mailing Address - Phone:203-503-3174
Mailing Address - Fax:203-503-6515
Practice Address - Street 1:226 DIXWELL AVENUE
Practice Address - Street 2:NORTHSIDE COMMUNITY OUTPATIENT SERVICES
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3456
Practice Address - Country:US
Practice Address - Phone:203-503-3470
Practice Address - Fax:203-503-3478
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007844101YM0800X
CT3657101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235918Medicaid