=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558113902
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL BALANCE THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2024
-----------------------------------------------------
Last Update Date | 04/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3208 WHITNEY AVE STE 1A
-----------------------------------------------------
City | HAMDEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06518-2158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 475-477-4190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 WOODS RD
-----------------------------------------------------
City | BETHANY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06524-3103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-605-8638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED MENTAL HEALTH THERAPIST
-----------------------------------------------------
Name | MRS. NICOLE ANN WETMORE
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 475-477-4190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------