Provider Demographics
NPI:1609177815
Name:SHORELINE WELLNESS CENTER, LLC.
Entity Type:Organization
Organization Name:SHORELINE WELLNESS CENTER, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARA
Authorized Official - Middle Name:M
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:203-931-1184
Mailing Address - Street 1:415 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4296
Mailing Address - Country:US
Mailing Address - Phone:203-931-1194
Mailing Address - Fax:203-931-1184
Practice Address - Street 1:415 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4296
Practice Address - Country:US
Practice Address - Phone:203-931-1194
Practice Address - Fax:203-931-1184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 103TC0700X, 1041C0700X, 106H00000X, 2084P0800X, 363LF0000X
CT003348163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty