Provider Demographics
NPI:1295215093
Name:MINDFUL THERAPY STUDIO LLC
Entity Type:Organization
Organization Name:MINDFUL THERAPY STUDIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-967-8941
Mailing Address - Street 1:29 DAVIDSON RD
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-1601
Mailing Address - Country:US
Mailing Address - Phone:860-967-8941
Mailing Address - Fax:
Practice Address - Street 1:16 RAE PALMER ROAD
Practice Address - Street 2:
Practice Address - City:MOODUS
Practice Address - State:CT
Practice Address - Zip Code:06423
Practice Address - Country:US
Practice Address - Phone:860-967-8941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-21
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008520261QM0850X
261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1265742597OtherNPI 1