Healthcare Provider Details

I. General information

NPI: 1326351412
Provider Name (Legal Business Name): BEHAVIORAL WELLNESS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2010
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BEHAVIORAL WELLNESS CLINIC 392 MERROW ROAD, SUITE E
TOLLAND CT
06084
US

IV. Provider business mailing address

BEHAVIORAL WELLNESS CLINIC 392 MERROW ROAD, SUITE E
TOLLAND CT
06084
US

V. Phone/Fax

Practice location:
  • Phone: 860-830-7838
  • Fax: 860-454-0667
Mailing address:
  • Phone: 860-830-7838
  • Fax: 860-454-0667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MONNICA T WILLIAMS
Title or Position: CLINICAL DIRECTOR
Credential:
Phone: 502-608-7483