Provider Demographics
NPI:1851640163
Name:ETHERAPY OF CONNECTICUT, LLC
Entity Type:Organization
Organization Name:ETHERAPY OF CONNECTICUT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:ROGALA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-308-8739
Mailing Address - Street 1:126 DAMASCUS RD
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3961
Mailing Address - Country:US
Mailing Address - Phone:860-882-3268
Mailing Address - Fax:203-265-0165
Practice Address - Street 1:1062 BARNES RD STE 106
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-6012
Practice Address - Country:US
Practice Address - Phone:860-882-3268
Practice Address - Fax:203-265-0165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006512104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty