Basic Information
| Provider Information | |||||||||
| NPI: | 1801438981 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARKETTE | ||||||||
| FirstName: | JOHN-TYLER | ||||||||
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| Credential: | COUNSELING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 COLUMBUS AVENUE | ||||||||
| Address2: | CREDENTIALING SPECIALIST | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033000 | ||||||||
| FaxNumber: | 2035033183 | ||||||||
| Practice Location | |||||||||
| Address1: | 62 GRANT STREET | ||||||||
| Address2: | GRANT STREET PARTNERSHIP | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065193456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033350 | ||||||||
| FaxNumber: | 2035033370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2019 | ||||||||
| LastUpdateDate: | 10/10/2019 | ||||||||
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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 | 101YP2500X | CT | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.