Basic Information
Provider Information | |||||||||
NPI: | 1124339577 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MURRAY | ||||||||
FirstName: | JEANNE | ||||||||
MiddleName: | P | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VANSCHAACK | ||||||||
OtherFirstName: | JEANNE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LMFT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1179 BOSTON POST RD FL 2 | ||||||||
Address2: |   | ||||||||
City: | OLD SAYBROOK | ||||||||
State: | CT | ||||||||
PostalCode: | 064754427 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8604808311 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 114 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | CT | ||||||||
PostalCode: | 064132131 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8606640787 | ||||||||
FaxNumber: | 8606641982 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2010 | ||||||||
LastUpdateDate: | 02/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 001338 | CT | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.