1740436344 NPI number — FORT HILL COUNSELORS LLC

Table of content: (NPI 1740436344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740436344 NPI number — FORT HILL COUNSELORS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORT HILL COUNSELORS 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:
1740436344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 FORT HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06340-4799
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-415-4551
Provider Business Mailing Address Fax Number:
860-415-4554

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 FORT HILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GROTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06340-4799
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-415-4551
Provider Business Practice Location Address Fax Number:
860-415-4554
Provider Enumeration Date:
08/14/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MACIOLEK
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
LICENSED PSYCHOLOGIST
Authorized Official Telephone Number:
860-415-4551

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  001048 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004057436 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060001048CT06 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 186856 . This is a "MHN/TRICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".