Healthcare Provider Details

I. General information

NPI: 1558809178
Provider Name (Legal Business Name): UNDIVIDED SOUL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2017
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 SIEMON COMPANY DR STE 315W
WATERTOWN CT
06795-2654
US

IV. Provider business mailing address

27 SIEMON COMPANY DR STE 315W
WATERTOWN CT
06795-2654
US

V. Phone/Fax

Practice location:
  • Phone: 203-697-8983
  • Fax: 844-436-9123
Mailing address:
  • Phone: 203-697-8983
  • Fax: 844-436-9123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3103
License Number StateCT

VIII. Authorized Official

Name: KATHRYN GELINAS
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: LPC
Phone: 203-697-8983