Provider Demographics
NPI:1518443027
Name:PROFESSIONAL INSTITUTE FOR CLINICAL SERVICE, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL INSTITUTE FOR CLINICAL SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRUDY
Authorized Official - Middle Name:TAMARA
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-539-5995
Mailing Address - Street 1:114 INDIAN HILL RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-1453
Mailing Address - Country:US
Mailing Address - Phone:860-539-5995
Mailing Address - Fax:
Practice Address - Street 1:360 BLOOMFIELD AVE STE 306
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-2700
Practice Address - Country:US
Practice Address - Phone:860-539-5995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0093511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty