Provider Demographics
NPI:1043517733
Name:MYSTIC THERAPY, LLC.
Entity Type:Organization
Organization Name:MYSTIC THERAPY, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DRUGAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, MS ED
Authorized Official - Phone:860-961-5702
Mailing Address - Street 1:21 NEW LONDON RD
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-2452
Mailing Address - Country:US
Mailing Address - Phone:860-961-5702
Mailing Address - Fax:866-740-0281
Practice Address - Street 1:49 WHITEHALL AVE
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-1966
Practice Address - Country:US
Practice Address - Phone:860-961-5702
Practice Address - Fax:866-740-0281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-16
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001404106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty