Provider Demographics
NPI:1467815449
Name:MIDDLESEX WELLNESS & MEDIATION, LLC
Entity Type:Organization
Organization Name:MIDDLESEX WELLNESS & MEDIATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO-BOUDINOT
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, NCC
Authorized Official - Phone:860-510-6130
Mailing Address - Street 1:80-1 PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:CT
Mailing Address - Zip Code:06426-1501
Mailing Address - Country:US
Mailing Address - Phone:860-510-6130
Mailing Address - Fax:860-760-6706
Practice Address - Street 1:80-1 PLAINS RD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1501
Practice Address - Country:US
Practice Address - Phone:860-510-6130
Practice Address - Fax:860-760-6706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 101YP2500X
CT1806106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty