| New Provenance Counseling Center, Llc | |
|
22 Saint James St Apt G Manchester CT 06040-5957 | |
| (959) 222-8548 | |
| Not Available |
| Full Name | New Provenance Counseling Center, Llc |
|---|---|
| Speciality | Social Worker |
| Location | 22 Saint James St Apt G, Manchester, Connecticut |
| Authorized Official Name and Position | Michelle Wortham (OWNER) |
| Authorized Official Contact | 9592228548 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| New Provenance Counseling Center, Llc 22 Saint James St Apt G Manchester CT 06040-5957 Ph: (959) 222-8548 | New Provenance Counseling Center, Llc 22 Saint James St Apt G Manchester CT 06040-5957 Ph: (959) 222-8548 |
| NPI Number | 1457949687 |
|---|---|
| Provider Enumeration Date | 01/04/2021 |
| Last Update Date | 01/04/2021 |
| Certification Date | 01/04/2021 |
| Medicare PECOS PAC ID | 3476934126 |
|---|---|
| Medicare Enrollment ID | O20220713001166 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1457949687 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Primary |
| Provider Name | Michelle Marie Wortham |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1316584956 PECOS PAC ID: 5294116943 Enrollment ID: I20220713001372 |
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