Healthcare Provider Details

I. General information

NPI: 1578078739
Provider Name (Legal Business Name): GREEN LOTUS CREATIVE HEALING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2017
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 KENWOOD ST
BERLIN CT
06037-2016
US

IV. Provider business mailing address

49 KENWOOD ST
BERLIN CT
06037-2016
US

V. Phone/Fax

Practice location:
  • Phone: 860-470-4304
  • Fax: 860-516-8286
Mailing address:
  • Phone: 860-470-4304
  • Fax: 860-516-8286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3209
License Number StateCT

VIII. Authorized Official

Name: BRITTANY QUINN
Title or Position: OWNER
Credential: LPC, ATR-BC, PMH-C
Phone: 860-470-4304