Provider Demographics
NPI:1053026187
Name:SELF LOVE THERAPY
Entity type:Organization
Organization Name:SELF LOVE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AVINA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:860-837-0302
Mailing Address - Street 1:PO BOX 1546
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-7546
Mailing Address - Country:US
Mailing Address - Phone:860-837-0302
Mailing Address - Fax:
Practice Address - Street 1:26 AMATO DR APT C
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3657
Practice Address - Country:US
Practice Address - Phone:860-985-5969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty