MEDICARE: MAIN STREET PSYCH AND WELLNESS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1124611447
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAIN STREET PSYCH AND WELLNESS PLLC

Provider Business Mailing Address
First Line	:	354 SPERRY RD
Second Line	:
City	:	BETHANY
State	:	CT
Zip	:	06524-3542
Country	:	US
Telephone Number	:	203-613-6454
Fax Number	:

Provider Business Practice Location Address
First Line	:	93 S MAIN ST
Second Line	:
City	:	BEACON FALLS
State	:	CT
Zip	:	06403-1447
Country	:	US
Telephone Number	:	203-397-6076
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CHRISTINA L LAPHAM
Credential	:	APRN
Telephone Number	:	203-613-6454

Provider Enumeration Date	:	02/17/2021
Last Update Date	:	02/17/2021

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Directions to “MAIN STREET PSYCH AND WELLNESS PLLC ” Practice Location

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