Provider Demographics
NPI:1740436344
Name:FORT HILL COUNSELORS LLC
Entity type:Organization
Organization Name:FORT HILL COUNSELORS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MACIOLEK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:860-415-4551
Mailing Address - Street 1:1 FORT HILL RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-4799
Mailing Address - Country:US
Mailing Address - Phone:860-415-4551
Mailing Address - Fax:860-415-4554
Practice Address - Street 1:1 FORT HILL RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4799
Practice Address - Country:US
Practice Address - Phone:860-415-4551
Practice Address - Fax:860-415-4554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001048103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004057436Medicaid
CT060001048CT06OtherANTHEM BC/BS
CT186856OtherMHN/TRICARE
CT060001048CT06OtherANTHEM BC/BS