Basic Information
| Provider Information | |||||||||
| NPI: | 1932255726 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOUTINHO | ||||||||
| FirstName: | JIM | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MS LPC LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 836 FARMINGTON AVE | ||||||||
| Address2: | SUITE 221B | ||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061191505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668876864 | ||||||||
| FaxNumber: | 8668876864 | ||||||||
| Practice Location | |||||||||
| Address1: | 836 FARMINGTON AVE | ||||||||
| Address2: | SUITE 221B | ||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061191505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668876864 | ||||||||
| FaxNumber: | 8668876864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 01/12/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 797 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 2231 | CT | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.