Healthcare Provider Details

I. General information

NPI: 1003096744
Provider Name (Legal Business Name): INTEGRATED WELLNESS GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446A BLAKE STREET SUITE 200
NEW HAVEN CT
06515-2216
US

IV. Provider business mailing address

446A BLAKE ST SUITE 200
NEW HAVEN CT
06515-1286
US

V. Phone/Fax

Practice location:
  • Phone: 203-387-9400
  • Fax: 888-772-2160
Mailing address:
  • Phone: 203-387-9400
  • Fax: 888-772-2160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number001636
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number006473
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number005442
License Number StateCT
# 6
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number002659
License Number StateCT

VIII. Authorized Official

Name: DR. MAYSA AKBAR
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D.
Phone: 203-387-9400