1225354988 NPI number — SHORELINE CENTER FOR FAMILY COUNSELING & PSYCHOTHERAPY, LLC

Table of content: (NPI 1225354988)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225354988 NPI number — SHORELINE CENTER FOR FAMILY COUNSELING & PSYCHOTHERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHORELINE CENTER FOR FAMILY COUNSELING & PSYCHOTHERAPY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225354988
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9 BUSINESS PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06405-2931
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-433-0299
Provider Business Mailing Address Fax Number:
203-643-2042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9 BUSINESS PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRANFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06405-2931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-433-0299
Provider Business Practice Location Address Fax Number:
203-643-2042
Provider Enumeration Date:
04/20/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EWING
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
203-433-0299

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  006202 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0808X , with the licence number: 005763 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)