Healthcare Provider Details

I. General information

NPI: 1396232187
Provider Name (Legal Business Name): WATERTOWN WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 GEORGETOWN DRIVE
WATERTOWN CT
06795
US

IV. Provider business mailing address

116 GEORGETOWN DR
WATERTOWN CT
06795-3349
US

V. Phone/Fax

Practice location:
  • Phone: 203-592-7898
  • Fax:
Mailing address:
  • Phone: 203-592-7898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number003013
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LAURA ANNE MANDERINO
Title or Position: OWNER/LICENSED PSYCHOTHERAPIST
Credential: LPC
Phone: 203-592-7898