Provider Demographics
NPI:1134988157
Name:BESPOKE THERAPY AND CONSULTING
Entity type:Organization
Organization Name:BESPOKE THERAPY AND CONSULTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHABAZZ
Authorized Official - Suffix:
Authorized Official - Credentials:DSW, LCSW
Authorized Official - Phone:860-491-7398
Mailing Address - Street 1:19A WEYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-6006
Mailing Address - Country:US
Mailing Address - Phone:860-491-7398
Mailing Address - Fax:
Practice Address - Street 1:19A WEYMOUTH RD
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-6006
Practice Address - Country:US
Practice Address - Phone:860-491-7398
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty