Provider Demographics
NPI:1164164430
Name:TRAILHEADS THERAPEUTIC SERVICES LLC
Entity Type:Organization
Organization Name:TRAILHEADS THERAPEUTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYANT
Authorized Official - Middle Name:M
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:203-980-6089
Mailing Address - Street 1:222 MCKEE ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4800
Mailing Address - Country:US
Mailing Address - Phone:203-980-6089
Mailing Address - Fax:
Practice Address - Street 1:222 MCKEE ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4800
Practice Address - Country:US
Practice Address - Phone:203-980-6089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-08
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)