Healthcare Provider Details

I. General information

NPI: 1124609987
Provider Name (Legal Business Name): JOURNEY TO SUCCESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 ARROW RD STE 103
WETHERSFIELD CT
06109-1301
US

IV. Provider business mailing address

61 ARROW RD STE 103
WETHERSFIELD CT
06109-1301
US

V. Phone/Fax

Practice location:
  • Phone: 959-245-4516
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: REVA MINGO
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: LPC, LADC
Phone: 959-245-4516