Provider Demographics
NPI:1962748517
Name:CANADA, THERESA J (EDD, NCC,LPC,DCC)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:J
Last Name:CANADA
Suffix:
Gender:F
Credentials:EDD, NCC,LPC,DCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 LA SALLE ST
Mailing Address - Street 2:15B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-4719
Mailing Address - Country:US
Mailing Address - Phone:212-663-4423
Mailing Address - Fax:
Practice Address - Street 1:412 MAIN ST
Practice Address - Street 2:NEW DIRECTIONS PSYCHOTHERAPY AND COUNSELING CENTER
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4730
Practice Address - Country:US
Practice Address - Phone:203-730-8775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-28
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000399101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional