Healthcare Provider Details

I. General information

NPI: 1689332983
Provider Name (Legal Business Name): CULTIVATE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2021
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S KENT RD
SOUTH KENT CT
06785-1112
US

IV. Provider business mailing address

108 S KENT RD
SOUTH KENT CT
06785-1112
US

V. Phone/Fax

Practice location:
  • Phone: 203-218-8788
  • Fax:
Mailing address:
  • Phone: 203-218-8788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: CLARA BURLINSON
Title or Position: MANAGER
Credential: LCSW
Phone: 203-218-8788