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General NPI Number Information
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NPI Number | 1568959815
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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 | 04/21/2018
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Last Update Date | 03/04/2021
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Provider Practice Location Address
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Address Line | 7 LINCOLN AVENUE
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City | GREENWICH
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State | CT
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Zip | 06830
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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 AVENUE
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City | GREENWICH
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State | CT
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Zip | 06830
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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 | OWNER/DIRECTOR
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Name | MS. JOANN S. BRONFMAN
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Credential | LCSW, PSY.D
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Telephone | 914-755-6472
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CT006838
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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