Provider Demographics
NPI:1871003293
Name:METAMORPHOSIS COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:METAMORPHOSIS COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED DRUG AND ALCOHOL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:DENNISSE
Authorized Official - Middle Name:
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LADC
Authorized Official - Phone:860-902-7050
Mailing Address - Street 1:106 FARMINGTON AVE STE 2B
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06053-2977
Mailing Address - Country:US
Mailing Address - Phone:860-902-7050
Mailing Address - Fax:860-902-7050
Practice Address - Street 1:106 FARMINGTON AVE STE 2B
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06053-2977
Practice Address - Country:US
Practice Address - Phone:860-902-7050
Practice Address - Fax:860-902-7050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000883101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008038649Medicaid