Provider Demographics
NPI:1508529173
Name:SOUTHBURY WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHBURY WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:REBECHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-915-7688
Mailing Address - Street 1:35 TIMBERLAND DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-1170
Mailing Address - Country:US
Mailing Address - Phone:203-915-7688
Mailing Address - Fax:
Practice Address - Street 1:2 POMPERAUG OFFICE PARK STE 206
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2291
Practice Address - Country:US
Practice Address - Phone:203-915-7688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1255641072Medicaid