Healthcare Provider Details

I. General information

NPI: 1568188662
Provider Name (Legal Business Name): MILL BROOK WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W PARK ST
LEBANON NH
03766-1378
US

IV. Provider business mailing address

448 DANA RD
NORTH POMFRET VT
05053-5052
US

V. Phone/Fax

Practice location:
  • Phone: 802-243-0215
  • Fax:
Mailing address:
  • Phone: 781-799-2611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MELISSA HAYES
Title or Position: OWNER/OPERATOR
Credential: LICSW
Phone: 802-243-0215