Provider Demographics
NPI:1912315631
Name:TEDESCO, JULIE
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:TEDESCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:664 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-4203
Mailing Address - Country:US
Mailing Address - Phone:860-309-7730
Mailing Address - Fax:
Practice Address - Street 1:664 PROSPECT AVENUE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117
Practice Address - Country:US
Practice Address - Phone:860-309-7730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-25
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002557101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional