=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689229676
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THRIVE WELLNESS & THERAPEUTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2019
-----------------------------------------------------
Last Update Date | 08/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 HIGH RIDGE RD STE 208 C/O SONDERCENTERES
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06905-1202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-539-0751
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 HIGH RIDGE RD STE 208
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06905-1202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-539-0751
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAYNA DIBIASI
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 631-806-5757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------