Healthcare Provider Details

I. General information

NPI: 1609177815
Provider Name (Legal Business Name): SHORELINE WELLNESS CENTER, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 11/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MAIN ST
WEST HAVEN CT
06516-4296
US

IV. Provider business mailing address

415 MAIN ST
WEST HAVEN CT
06516-4296
US

V. Phone/Fax

Practice location:
  • Phone: 203-931-1194
  • Fax: 203-931-1184
Mailing address:
  • Phone: 203-931-1194
  • Fax: 203-931-1184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
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 Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number003348
License Number StateCT
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. CARA M POWERS
Title or Position: COUNSELOR/OWNER
Credential: LPC
Phone: 203-931-1184