Healthcare Provider Details

I. General information

NPI: 1457216541
Provider Name (Legal Business Name): INTEGRATIVE WELLNESS & THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 BALDWIN RD
ORANGE CT
06477-1118
US

IV. Provider business mailing address

836 BALDWIN RD
ORANGE CT
06477-1118
US

V. Phone/Fax

Practice location:
  • Phone: 203-589-2732
  • Fax:
Mailing address:
  • Phone: 203-589-2732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: EMAJAE RICKETTS
Title or Position: OWNER
Credential: LPC
Phone: 203-589-2732