Healthcare Provider Details

I. General information

NPI: 1780120683
Provider Name (Legal Business Name): BWELL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2017
Last Update Date: 01/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 SHERMAN HILL RD BUILDING D, SUITE 104
WOODBURY CT
06798-3651
US

IV. Provider business mailing address

65 CABLES AVE APT 13
WATERBURY CT
06710-1645
US

V. Phone/Fax

Practice location:
  • Phone: 845-659-9391
  • Fax:
Mailing address:
  • Phone: 845-659-9391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9565
License Number StateCT

VIII. Authorized Official

Name: BECKY MAYER
Title or Position: OWNER
Credential: LCSW
Phone: 845-659-9391