Provider Demographics
NPI:1174974471
Name:SEPULVEDA, JOMARY (LPC)
Entity type:Individual
Prefix:DR
First Name:JOMARY
Middle Name:
Last Name:SEPULVEDA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:DR
Other - First Name:JOMARY
Other - Middle Name:
Other - Last Name:SEPULVEDA-BETANCOURT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:400 COLUMBUS AVE
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 1:400 COLUMBUS AVE
Practice Address - Street 2:APC
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519
Practice Address - Country:US
Practice Address - Phone:203-503-3673
Practice Address - Fax:203-503-3600
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3521101YP2500X
CT4700103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235918Medicaid