Provider Demographics
NPI:1578704219
Name:CENTRAL CONNECTICUT PSYCHOTHERAPY LLC
Entity Type:Organization
Organization Name:CENTRAL CONNECTICUT PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKUP
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-337-7144
Mailing Address - Street 1:23 LIBERTY DR
Mailing Address - Street 2:SUITE B-1
Mailing Address - City:HEBRON
Mailing Address - State:CT
Mailing Address - Zip Code:06248-1553
Mailing Address - Country:US
Mailing Address - Phone:860-337-7144
Mailing Address - Fax:860-337-7155
Practice Address - Street 1:23 LIBERTY DR
Practice Address - Street 2:SUITE 23 B-1
Practice Address - City:HEBRON
Practice Address - State:CT
Practice Address - Zip Code:06248
Practice Address - Country:US
Practice Address - Phone:860-337-7144
Practice Address - Fax:860-337-7155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-10
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006447261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1033187539OtherINDIVIDUAL NPI