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General NPI Number Information
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NPI Number | 1598209116
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Entity Type | Organization
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Legal Business Name | STONY CREEK WELLNESS GROUP, LLC
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Dates
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Enumeration Date | 12/16/2016
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Last Update Date | 12/16/2016
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Provider Practice Location Address
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Address Line | 2415 BOSTON POST RD UNIT 12
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City | GUILFORD
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State | CT
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Zip | 06437-4348
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Country | US
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Telephone | 203-693-4566
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Fax | 203-457-5970
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Provider Business Mailing Address
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Address Line | 2415 BOSTON POST RD UNIT 12
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City | GUILFORD
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State | CT
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Zip | 06437-4348
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Country | US
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Telephone | 203-693-4566
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Fax | 203-457-5970
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Authorized Official
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Title or Position | OWNER
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Name | TRICIA L MIGNOSA
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Credential | APRN
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Telephone | 203-693-4566
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 1922
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 9481
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License Number State | CT
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Taxonomy #3
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 5763
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License Number State | CT
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