Provider Demographics
NPI:1003209115
Name:AZALEA COUNSELING & WELLNESS, LLC
Entity Type:Organization
Organization Name:AZALEA COUNSELING & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-888-2516
Mailing Address - Street 1:100 MARKET SQ
Mailing Address - Street 2:SUITE 16A
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2921
Mailing Address - Country:US
Mailing Address - Phone:860-888-2516
Mailing Address - Fax:
Practice Address - Street 1:100 MARKET SQ
Practice Address - Street 2:SUITE 16A
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2921
Practice Address - Country:US
Practice Address - Phone:860-888-2516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008089251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004025193Medicaid