Provider Demographics
NPI:1871876268
Name:WETMORE, DANA (LPC)
Entity type:Individual
Prefix:MRS
First Name:DANA
Middle Name:
Last Name:WETMORE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:DANA
Other - Middle Name:M
Other - Last Name:MONGILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:400 COLUMBUS AVENUE
Mailing Address - Street 2:CREDENTIALING SPECIALIST
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1233
Mailing Address - Country:US
Mailing Address - Phone:203-503-3174
Mailing Address - Fax:203-503-3183
Practice Address - Street 1:913 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3926
Practice Address - Country:US
Practice Address - Phone:203-503-3660
Practice Address - Fax:203-503-3562
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2439101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008049504Medicaid