Healthcare Provider Details

I. General information

NPI: 1639888431
Provider Name (Legal Business Name): MINDFUL GROWTH UNLIMITED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2022
Last Update Date: 11/21/2022
Certification Date: 11/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1176 FARMINGTON AVE
BERLIN CT
06037-2302
US

IV. Provider business mailing address

1075 ORCHARD RD
BERLIN CT
06037-3529
US

V. Phone/Fax

Practice location:
  • Phone: 860-515-8844
  • Fax:
Mailing address:
  • Phone: 860-515-8844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MELISSA URRUNAGA
Title or Position: OWNER
Credential: LPC
Phone: 860-515-8844