Provider Demographics
NPI:1174292460
Name:BACKCOUNTRY WELLNESS LLC
Entity Type:Organization
Organization Name:BACKCOUNTRY WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:STEINER
Authorized Official - Last Name:BRONFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-992-1700
Mailing Address - Street 1:7 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-5794
Mailing Address - Country:US
Mailing Address - Phone:203-992-1700
Mailing Address - Fax:
Practice Address - Street 1:6 OLD MILL RD
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-3345
Practice Address - Country:US
Practice Address - Phone:203-992-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BACKCOUNTRY WELLNESS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-09-09
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility