=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134606262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL CREATIVITY STUDIO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2018
-----------------------------------------------------
Last Update Date | 07/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 EXCHANGE ST
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06513-3921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-668-9725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 EXCHANGE ST
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06513-3921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-668-9725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CATHERINE J MACRAE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 203-668-9725
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 006108
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------