Healthcare Provider Details

I. General information

NPI: 1114851227
Provider Name (Legal Business Name): NORTHEAST WELLNESS CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 KINGS HWY
FAIRFIELD CT
06824-5319
US

IV. Provider business mailing address

1201 KINGS HWY
FAIRFIELD CT
06824-5319
US

V. Phone/Fax

Practice location:
  • Phone: 203-913-9213
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DAMARIS TORRES
Title or Position: MANAGER
Credential: APRN, PMHNP
Phone: 203-913-9213