Provider Demographics
NPI:1548760267
Name:EMBRACE LIFE THERAPEUTIC SERVICES, LLC
Entity Type:Organization
Organization Name:EMBRACE LIFE THERAPEUTIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSE PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEZARES
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, NCC
Authorized Official - Phone:860-833-1919
Mailing Address - Street 1:315 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3821
Mailing Address - Country:US
Mailing Address - Phone:860-833-1919
Mailing Address - Fax:
Practice Address - Street 1:81 W MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-4221
Practice Address - Country:US
Practice Address - Phone:860-833-1919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3283101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty