Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP1600X | Pastoral Counselor | 002270 | CT |
NPI | 1003459389 |
---|---|
Provider Name | Frederick Streets |
First Address | Stratford, CT 06614-3925 |
Second Address | Stratford, CT 06614-3925 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/10/2019 |
Last Update Date | 19/10/2019 |