Provider Demographics
NPI:1598209116
Name:STONY CREEK WELLNESS GROUP, LLC
Entity Type:Organization
Organization Name:STONY CREEK WELLNESS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MIGNOSA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:203-693-4566
Mailing Address - Street 1:2415 BOSTON POST RD
Mailing Address - Street 2:UNIT 12
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-4348
Mailing Address - Country:US
Mailing Address - Phone:203-693-4566
Mailing Address - Fax:203-457-5970
Practice Address - Street 1:2415 BOSTON POST RD
Practice Address - Street 2:UNIT 12
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-4348
Practice Address - Country:US
Practice Address - Phone:203-693-4566
Practice Address - Fax:203-457-5970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-16
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1922101YP2500X
CT94811041C0700X
CT5763363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty