=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578029377
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIND BODY COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2019
-----------------------------------------------------
Last Update Date | 08/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 RIVERVIEW CTR STE 240
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06457-3489
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-373-2828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 HUNTING HILL AVE
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06457-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-373-2828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARISA VALDISERRA
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 860-373-2828
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------