Provider Demographics
NPI:1497142756
Name:JOLANTA MARYANSKA THERAPY, LLC
Entity Type:Organization
Organization Name:JOLANTA MARYANSKA THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOLANTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARYANSKA
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:203-376-3639
Mailing Address - Street 1:30 BARKER HILL DR
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2351
Mailing Address - Country:US
Mailing Address - Phone:203-376-3639
Mailing Address - Fax:
Practice Address - Street 1:66 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3032
Practice Address - Country:US
Practice Address - Phone:203-376-3639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001692251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008057974Medicaid