Provider Demographics
NPI:1275279697
Name:SOUTHWINDSORPSYCHOTHERAPY
Entity Type:Organization
Organization Name:SOUTHWINDSORPSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:JESKI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-324-2840
Mailing Address - Street 1:512 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2413
Mailing Address - Country:US
Mailing Address - Phone:860-978-5916
Mailing Address - Fax:
Practice Address - Street 1:1169 ELLINGTON RD
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3515
Practice Address - Country:US
Practice Address - Phone:860-978-5916
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)