Healthcare Provider Details

I. General information

NPI: 1417862566
Provider Name (Legal Business Name): SCULPTED SPIRIT MENTAL HEALTH COUNSELING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 MEADOW ST APT 1
DANBURY CT
06810-3436
US

IV. Provider business mailing address

169 MADISON AVE STE 15830
NEW YORK NY
10016-5101
US

V. Phone/Fax

Practice location:
  • Phone: 201-255-7814
  • Fax:
Mailing address:
  • Phone: 201-255-7814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DAESEAN CLAY
Title or Position: SOLE MEMBER
Credential:
Phone: 201-255-7814