Provider Demographics
NPI:1710452255
Name:CT KIDS MATTER LLC
Entity Type:Organization
Organization Name:CT KIDS MATTER LLC
Other - Org Name:BEDROCK WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:R
Authorized Official - Last Name:LASELLE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCSW,MS,MPA
Authorized Official - Phone:203-599-1492
Mailing Address - Street 1:416 HIGHLAND AVE STE B
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-2531
Mailing Address - Country:US
Mailing Address - Phone:203-599-1492
Mailing Address - Fax:
Practice Address - Street 1:416 HIGHLAND AVE STE B
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-2531
Practice Address - Country:US
Practice Address - Phone:203-599-1492
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-11
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008083434Medicaid