Healthcare Provider Details

I. General information

NPI: 1407253404
Provider Name (Legal Business Name): HEAL YOURSELF, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2014
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 HEMLOCK HILL RD
CLINTON CT
06413-1108
US

IV. Provider business mailing address

10 HEMLOCK HILL RD
CLINTON CT
06413-1108
US

V. Phone/Fax

Practice location:
  • Phone: 860-664-3651
  • Fax:
Mailing address:
  • Phone: 860-664-3651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number000520
License Number StateCT

VIII. Authorized Official

Name: TAMARA ALEXANDROVNA POTSELUEVA
Title or Position: VICE PRESIDENT
Credential: ND
Phone: 860-664-3651