Provider Demographics
NPI:1104348192
Name:THE CENTER FOR EMOTIONAL HEALING, LLC
Entity type:Organization
Organization Name:THE CENTER FOR EMOTIONAL HEALING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:860-368-8665
Mailing Address - Street 1:50 STURBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-9037
Mailing Address - Country:US
Mailing Address - Phone:860-368-8665
Mailing Address - Fax:
Practice Address - Street 1:307 EAST STREET
Practice Address - Street 2:UNIT 1
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062
Practice Address - Country:US
Practice Address - Phone:860-368-8665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-11
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2783251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1740526672Medicaid