Provider Demographics
NPI:1033759196
Name:MANA PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:MANA PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND LPC
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BOUTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:203-240-7075
Mailing Address - Street 1:10 N MAIN ST STE 305
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1901
Mailing Address - Country:US
Mailing Address - Phone:203-240-7075
Mailing Address - Fax:
Practice Address - Street 1:10 N MAIN ST STE 305
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1901
Practice Address - Country:US
Practice Address - Phone:203-240-7075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)