Provider Demographics
NPI:1598105439
Name:BROCKETT, EUGENIA M (LMFT)
Entity Type:Individual
Prefix:
First Name:EUGENIA
Middle Name:M
Last Name:BROCKETT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 E MAIN ST
Mailing Address - Street 2:4TH FLOOR ADMINISTRATION
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-2310
Mailing Address - Country:US
Mailing Address - Phone:203-574-9000
Mailing Address - Fax:203-574-9006
Practice Address - Street 1:70 PINE ST
Practice Address - Street 2:PINE ST SCHOOL BASED
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06710-2169
Practice Address - Country:US
Practice Address - Phone:203-756-7287
Practice Address - Fax:203-596-0722
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT637106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12659263OtherCAQH
CT004039202Medicaid