Healthcare Provider Details

I. General information

NPI: 1609587187
Provider Name (Legal Business Name): WAVES OF HEALING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 SQUASH HOLLOW RD
NEW MILFORD CT
06776-5403
US

IV. Provider business mailing address

54 SQUASH HOLLOW RD
NEW MILFORD CT
06776-5403
US

V. Phone/Fax

Practice location:
  • Phone: 203-460-0584
  • Fax:
Mailing address:
  • Phone: 203-460-0584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: AMANDA WIRAG
Title or Position: BUSINESS OWNER
Credential: LPC
Phone: 203-460-0584