Provider Demographics
NPI:1932308061
Name:SLACK, MARLA S (LPC)
Entity Type:Individual
Prefix:MS
First Name:MARLA
Middle Name:S
Last Name:SLACK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:YALESVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2253
Mailing Address - Country:US
Mailing Address - Phone:860-416-1464
Mailing Address - Fax:
Practice Address - Street 1:300 CHURCH ST
Practice Address - Street 2:
Practice Address - City:YALESVILLE
Practice Address - State:CT
Practice Address - Zip Code:06492-2253
Practice Address - Country:US
Practice Address - Phone:860-416-1464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001271101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health