Provider Demographics
NPI:1760856181
Name:KMG THERAPY AND CONSULTING LLC
Entity Type:Organization
Organization Name:KMG THERAPY AND CONSULTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GALLAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-917-1779
Mailing Address - Street 1:1075 E LAKE RD
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CT
Mailing Address - Zip Code:06370-1818
Mailing Address - Country:US
Mailing Address - Phone:860-917-1779
Mailing Address - Fax:860-447-8122
Practice Address - Street 1:481 GOLD STAR HWY
Practice Address - Street 2:SUITE 301
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6702
Practice Address - Country:US
Practice Address - Phone:860-917-1779
Practice Address - Fax:860-447-8122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-23
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT88231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0006568OtherVALUEOPTIONS CT BHP
CT008056500Medicaid
CTD300184136OtherMEDICARE PTAN
CT13515495OtherCOUNCIL FOR AFFORDABLE QUALITY HEALTH (CAQH)
CT544181OtherMANAGED HEALTH NETWORK (MHN)