Provider Demographics
NPI:1386940500
Name:SUPPORTIVE COUNSELING SERVICES
Entity type:Organization
Organization Name:SUPPORTIVE COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:B
Authorized Official - Last Name:MELQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:860-305-6164
Mailing Address - Street 1:41 KENSINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-5421
Mailing Address - Country:US
Mailing Address - Phone:860-305-6164
Mailing Address - Fax:
Practice Address - Street 1:843 MAIN ST
Practice Address - Street 2:SUITE 11
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-6020
Practice Address - Country:US
Practice Address - Phone:860-305-6164
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-05
Last Update Date:2011-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001277101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001277OtherCT LICENSED PROFESSIONAL COUNSELOR