Provider Demographics
NPI:1720491087
Name:INTROSPECTIVE COUNSELING LLC
Entity type:Organization
Organization Name:INTROSPECTIVE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:REARDON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:860-845-2068
Mailing Address - Street 1:22 PINE ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-6948
Mailing Address - Country:US
Mailing Address - Phone:860-845-2068
Mailing Address - Fax:860-845-2365
Practice Address - Street 1:22 PINE ST
Practice Address - Street 2:SUITE 205
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-6948
Practice Address - Country:US
Practice Address - Phone:860-845-2068
Practice Address - Fax:860-845-2365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001140106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004257334Medicaid