Provider Demographics
NPI:1568959815
Name:BACKCOUNTRY WELLNESS LLC
Entity Type:Organization
Organization Name:BACKCOUNTRY WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:S
Authorized Official - Last Name:BRONFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, PSYD
Authorized Official - Phone:914-755-6472
Mailing Address - Street 1:7 LINCOLN AVENUE
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830
Mailing Address - Country:US
Mailing Address - Phone:203-992-1700
Mailing Address - Fax:
Practice Address - Street 1:7 LINCOLN AVENUE
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830
Practice Address - Country:US
Practice Address - Phone:203-992-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-21
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT0068381041C0700X
261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty