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229 Bacon Pond Rd Apt 154 Woodbury CT 06798-3692 | |
| (860) 575-8700 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Counselor - Professional |
| Location | 229 Bacon Pond Rd Apt 154, Woodbury, Connecticut |
| Authorized Official Name and Position | Lisbeth Gannon (OWNER) |
| Authorized Official Contact | 8605758700 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 162 Roxbury CT 06783-0162 Ph: (860) 575-8700 | 229 Bacon Pond Rd Apt 154 Woodbury CT 06798-3692 Ph: (860) 575-8700 |
| NPI Number | 1740899491 |
|---|---|
| Provider Enumeration Date | 07/29/2020 |
| Last Update Date | 10/21/2020 |
| Certification Date | 10/21/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1740899491 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YP2500X | Counselor - Professional | (* (Not Available)) | Primary |
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