Basic Information
| Provider Information | |||||||||
| NPI: | 1467982504 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THERAPEUTIC ALLIANCE OF CONNECTICUT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 174 SOUTH RD STE 125 | ||||||||
| Address2: | |||||||||
| City: | ENFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060824414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609661004 | ||||||||
| FaxNumber: | 8607884090 | ||||||||
| Practice Location | |||||||||
| Address1: | 174 SOUTH RD STE 125 | ||||||||
| Address2: | |||||||||
| City: | ENFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060824414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609661004 | ||||||||
| FaxNumber: | 8607884090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | DURAN | ||||||||
| AuthorizedOfficialFirstName: | JULIO | ||||||||
| AuthorizedOfficialMiddleName: | RENE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8609661004 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | PMHNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 7027 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.