Healthcare Provider Details

I. General information

NPI: 1144064643
Provider Name (Legal Business Name): JEANETTE ELLEN MAILS LCAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2024
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 THORPE AVE
WALLINGFORD CT
06492-1999
US

IV. Provider business mailing address

35 THORPE AVE STE 104
WALLINGFORD CT
06492-1948
US

V. Phone/Fax

Practice location:
  • Phone: 203-779-5799
  • Fax:
Mailing address:
  • Phone: 203-779-5799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87001705A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: