=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609177815
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHORELINE WELLNESS CENTER, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2010
-----------------------------------------------------
Last Update Date | 11/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 415 MAIN ST
-----------------------------------------------------
City | WEST HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06516-4296
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-931-1194
-----------------------------------------------------
Fax | 203-931-1184
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 MAIN ST
-----------------------------------------------------
City | WEST HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06516-4296
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-931-1194
-----------------------------------------------------
Fax | 203-931-1184
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR/OWNER
-----------------------------------------------------
Name | MRS. CARA M POWERS
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 203-931-1184
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 163WP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | 003348
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------