Provider Demographics
NPI:1396232187
Name:WATERTOWN WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:WATERTOWN WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSED PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:MANDERINO
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:203-592-7898
Mailing Address - Street 1:116 GEORGETOWN DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-3349
Mailing Address - Country:US
Mailing Address - Phone:203-592-7898
Mailing Address - Fax:
Practice Address - Street 1:116 GEORGETOWN DRIVE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795
Practice Address - Country:US
Practice Address - Phone:203-592-7898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003013101YP2500X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty