Provider Demographics
NPI:1407227812
Name:PROFESSIONAL FAMILY THERAPY-LLC
Entity Type:Organization
Organization Name:PROFESSIONAL FAMILY THERAPY-LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:DUMAS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:860-281-9588
Mailing Address - Street 1:222 MCKEE ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4800
Mailing Address - Country:US
Mailing Address - Phone:844-584-3727
Mailing Address - Fax:
Practice Address - Street 1:222 MCKEE ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4800
Practice Address - Country:US
Practice Address - Phone:844-584-3727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-12
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000873106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004025029Medicaid