Healthcare Provider Details

I. General information

NPI: 1861911455
Provider Name (Legal Business Name): SMALL VICTORIES WELLNESS SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2017
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 MAIN ST STE 2D
MIDDLETOWN CT
06457-3375
US

IV. Provider business mailing address

360 MAIN ST STE 2D
MIDDLETOWN CT
06457-3375
US

V. Phone/Fax

Practice location:
  • Phone: 860-248-6041
  • Fax:
Mailing address:
  • Phone: 860-248-6041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. CARRISSA PHIPPS
Title or Position: LICENSED PSYCHOLOGIST
Credential: PHD
Phone: 860-740-2041