MEDICARE: A HEALTHY MIND LLC

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	1041C0700X	Clinical Social Worker	007548	CT
2	101YP2500X	Professional Counselor	2634

General Provider Information

NPI Number	:	1992161681
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A HEALTHY MIND LLC

Provider Business Mailing Address
First Line	:	PO BOX 1233
Second Line	:
City	:	TORRINGTON
State	:	CT
Zip	:	06790-1233
Country	:	US
Telephone Number	:	860-459-1134
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 MIGEON AVE
Second Line	:
City	:	TORRINGTON
State	:	CT
Zip	:	06790-4861
Country	:	US
Telephone Number	:	860-459-1134
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. RUTH L SIMONCELLI
Credential	:	L.P.C
Telephone Number	:	860-459-1134

Provider Enumeration Date	:	01/11/2016
Last Update Date	:	07/06/2016

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Directions to “A HEALTHY MIND LLC ” Practice Location

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