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General NPI Number Information
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NPI Number | 1780120683
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Entity Type | Organization
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Legal Business Name | BWELL LLC
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Dates
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Enumeration Date | 01/16/2017
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Last Update Date | 01/16/2017
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Provider Practice Location Address
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Address Line | 43 SHERMAN HILL RD BUILDING D, SUITE 104
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City | WOODBURY
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State | CT
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Zip | 06798-3651
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Country | US
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Telephone | 845-659-9391
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Fax |
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Provider Business Mailing Address
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Address Line | 65 CABLES AVE APT 13
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City | WATERBURY
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State | CT
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Zip | 06710-1645
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Country | US
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Telephone | 845-659-9391
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BECKY MAYER
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Credential | LCSW
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Telephone | 845-659-9391
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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 | 9565
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License Number State | CT
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