Healthcare Provider Details

I. General information

NPI: 1891454765
Provider Name (Legal Business Name): PSYCHIATRIC WELLNESS CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2021
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 JUNIPER LANE
WEST HARTFORD CT
06117
US

IV. Provider business mailing address

P.O. BOX 370602 12 CROSSROADS PLAZA
WEST HARTFORD CT
06117
US

V. Phone/Fax

Practice location:
  • Phone: 860-414-4787
  • Fax:
Mailing address:
  • Phone: 860-414-4787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CLARISSE FAIRBANKS
Title or Position: OWNER, AUTHORIZED OFFICIAL
Credential: DNP, APRN, PMHCNS
Phone: 860-414-4787