Healthcare Provider Details

I. General information

NPI: 1104149293
Provider Name (Legal Business Name): WEAVE YOUR LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2010
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

963 QUEEN ST SUITE C
SOUTHINGTON CT
06489-1282
US

IV. Provider business mailing address

963 QUEEN ST SUITE C
SOUTHINGTON CT
06489-1282
US

V. Phone/Fax

Practice location:
  • Phone: 860-819-8570
  • Fax:
Mailing address:
  • Phone: 860-819-8570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number006194
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number006194
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number000729
License Number StateCT

VIII. Authorized Official

Name: AUDREY L BENNETT
Title or Position: MANAGER
Credential:
Phone: 860-819-8570