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General NPI Number Information
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NPI Number | 1174292460
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Entity Type | Organization
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Legal Business Name | BACKCOUNTRY WELLNESS LLC
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Dates
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Enumeration Date | 09/09/2021
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Last Update Date | 09/23/2021
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Provider Practice Location Address
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Address Line | 6 OLD MILL RD
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City | GREENWICH
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State | CT
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Zip | 06830-3345
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Country | US
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Telephone | 203-992-1700
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Fax |
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Provider Business Mailing Address
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Address Line | 7 LINCOLN AVE
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City | GREENWICH
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State | CT
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Zip | 06830-5794
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Country | US
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Telephone | 203-992-1700
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE CLINICAL DIRECTOR
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Name | JOANN STEINER BRONFMAN
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Credential |
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Telephone | 203-992-1700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number |
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License Number State |
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