Provider Demographics
NPI:1255849725
Name:RELEASE WELLNESS
Entity Type:Organization
Organization Name:RELEASE WELLNESS
Other - Org Name:RELEASE WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER COUNSELOR/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LOVELL
Authorized Official - Suffix:
Authorized Official - Credentials:MS MED LPC
Authorized Official - Phone:860-937-6210
Mailing Address - Street 1:1320 BERLIN TPKE
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1060
Mailing Address - Country:US
Mailing Address - Phone:860-818-3122
Mailing Address - Fax:
Practice Address - Street 1:805 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1670
Practice Address - Country:US
Practice Address - Phone:860-937-6210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2883101YP2500X, 251E00000X, 261QM0850X, 261QM0855X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT=========Medicaid