Provider Demographics
NPI:1679031140
Name:PHETSAMON DILULLO
Entity Type:Organization
Organization Name:PHETSAMON DILULLO
Other - Org Name:CONNECTICUT THERAPEUTIC COUNSELING LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHETSAMON
Authorized Official - Middle Name:
Authorized Official - Last Name:DILULLO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:413-896-0874
Mailing Address - Street 1:25 CLERMONT ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3904
Mailing Address - Country:US
Mailing Address - Phone:413-896-0874
Mailing Address - Fax:
Practice Address - Street 1:25 CLERMONT ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3904
Practice Address - Country:US
Practice Address - Phone:413-896-0874
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONNECTICUT THERAPEUTIC COUNSELING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-04
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health