Provider Demographics
NPI:1104533579
Name:JARVIS, MICHAEL TODD (LPC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TODD
Last Name:JARVIS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:TODD
Other - Middle Name:WISDOM
Other - Last Name:JARVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:5 CONCORD WAY
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-5746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 CONCORD WAY
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-5746
Practice Address - Country:US
Practice Address - Phone:203-942-8483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003463101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty