Healthcare Provider Details

I. General information

NPI: 1487079885
Provider Name (Legal Business Name): BRAIN MIND BODY PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2014
Last Update Date: 03/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 POST RD W STE 1
WESTPORT CT
06880-4652
US

IV. Provider business mailing address

6 STEEP HILL RD
WESTON CT
06883-1731
US

V. Phone/Fax

Practice location:
  • Phone: 203-293-4395
  • Fax:
Mailing address:
  • Phone: 203-557-0305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number008202
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MARIANA FRAGA-ZAPF
Title or Position: PSYCHOTHERAPIST
Credential: LCSW
Phone: 203-293-4395