Provider Demographics
NPI:1700021029
Name:BAYSIDE COUNSELING, LLC
Entity Type:Organization
Organization Name:BAYSIDE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:OTRIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:860-399-9500
Mailing Address - Street 1:1921 BOSTON POST RD STE 207
Mailing Address - Street 2:PO BOX 47
Mailing Address - City:WESTBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06498-2171
Mailing Address - Country:US
Mailing Address - Phone:860-399-9500
Mailing Address - Fax:888-232-7553
Practice Address - Street 1:1921 BOSTON POST RD
Practice Address - Street 2:#207
Practice Address - City:WESTBROOK
Practice Address - State:CT
Practice Address - Zip Code:06498-2171
Practice Address - Country:US
Practice Address - Phone:860-399-9500
Practice Address - Fax:888-232-7553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001294101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008013938Medicaid