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General NPI Number Information
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NPI Number | 1891153474
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Entity Type | Organization
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Legal Business Name | MINDFUL MEDIATION LLC
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Dates
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Enumeration Date | 02/10/2016
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Last Update Date | 02/10/2016
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Provider Practice Location Address
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Address Line | 85 STATE ST STE D
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City | NORTH HAVEN
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State | CT
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Zip | 06473-2240
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Country | US
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Telephone | 203-376-0220
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Fax |
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Provider Business Mailing Address
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Address Line | 49 ENGLEWOOD DR
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City | NEW HAVEN
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State | CT
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Zip | 06515-2309
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SHALYN ROSE
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Credential | LCSW
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Telephone | 203-376-0220
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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 | 001770
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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 | 008003
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License Number State | CT
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