Provider Demographics
NPI:1457711954
Name:TERAPIA DE JUEGO, LLC
Entity type:Organization
Organization Name:TERAPIA DE JUEGO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:MADELYN
Authorized Official - Last Name:TONNING
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-883-8135
Mailing Address - Street 1:30 MYANO LN
Mailing Address - Street 2:SUITE 20
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-4532
Mailing Address - Country:US
Mailing Address - Phone:220-388-3813
Mailing Address - Fax:203-883-8139
Practice Address - Street 1:30 MYANO LN
Practice Address - Street 2:SUITE 20
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-4532
Practice Address - Country:US
Practice Address - Phone:220-388-3813
Practice Address - Fax:203-883-8139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR071645251S00000X
CT001536251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008017104Medicaid