Provider Demographics
NPI:1730400318
Name:MICHELLE BUSSOLOTTI, LMFT
Entity type:Organization
Organization Name:MICHELLE BUSSOLOTTI, LMFT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BUSSOLOTTI
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:860-961-4951
Mailing Address - Street 1:2 BRIAR HILL DR
Mailing Address - Street 2:
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-1847
Mailing Address - Country:US
Mailing Address - Phone:860-961-4951
Mailing Address - Fax:860-405-0563
Practice Address - Street 1:481 GOLD STAR HWY
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6702
Practice Address - Country:US
Practice Address - Phone:860-961-4951
Practice Address - Fax:860-405-0563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001284106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty