Healthcare Provider Details

I. General information

NPI: 1639516032
Provider Name (Legal Business Name): ROAD TO WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2013
Last Update Date: 05/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2911 DIXWELL AVE SUITE B-5
HAMDEN CT
06518-3195
US

IV. Provider business mailing address

2911 DIXWELL AVE SUITE B-5
HAMDEN CT
06518-3195
US

V. Phone/Fax

Practice location:
  • Phone: 203-654-1367
  • Fax: 203-889-4926
Mailing address:
  • Phone: 203-654-1367
  • Fax: 203-889-4926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number003271
License Number StateCT

VIII. Authorized Official

Name: DR. ALEESHA DENISE GRIER-ROGERS
Title or Position: MANAGER/OWNER
Credential: PSY.D.
Phone: 203-654-1367