Healthcare Provider Details

I. General information

NPI: 1447894209
Provider Name (Legal Business Name): MINDFUL THERAPY STUDIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2019
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 RAE PALMER RD
MOODUS CT
06469-1195
US

IV. Provider business mailing address

16 RAE PALMER RD
MOODUS CT
06469-1195
US

V. Phone/Fax

Practice location:
  • Phone: 860-967-8941
  • Fax:
Mailing address:
  • Phone: 860-967-8941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LISA ROGERS
Title or Position: OWNER/OPERATOR
Credential: LCSW
Phone: 860-967-8941