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General NPI Number Information
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NPI Number | 1033750526
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Entity Type | Organization
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Legal Business Name | HEALING WATERS/LIFE CHANGERS LLC
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Dates
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Enumeration Date | 10/05/2019
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Last Update Date | 10/05/2019
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Provider Practice Location Address
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Address Line | 1229 ALBANY AVE STE 4
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City | HARTFORD
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State | CT
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Zip | 06112-2156
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Country | US
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Telephone | 860-246-2323
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Fax |
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Provider Business Mailing Address
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Address Line | 1229 ALBANY AVE STE 4
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City | HARTFORD
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State | CT
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Zip | 06112-2156
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Country | US
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Telephone | 860-246-2323
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. JACQUELINE PHILLIPS
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Credential |
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Telephone | 860-729-7239
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3245S0500X
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Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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