Healthcare Provider Details

I. General information

NPI: 1306688593
Provider Name (Legal Business Name): TEAL DRAGON HEALING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1177 HIGH RIDGE RD STE 119
STAMFORD CT
06905-1221
US

IV. Provider business mailing address

1177 HIGH RIDGE RD STE 119
STAMFORD CT
06905-1221
US

V. Phone/Fax

Practice location:
  • Phone: 831-272-2676
  • Fax:
Mailing address:
  • Phone: 831-272-2676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ADENA BLICKSTEIN
Title or Position: CEO
Credential: MD
Phone: 917-613-0886