Provider Demographics
NPI:1891454765
Name:PSYCHIATRIC WELLNESS CARE, LLC
Entity Type:Organization
Organization Name:PSYCHIATRIC WELLNESS CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARISSE
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:860-414-4787
Mailing Address - Street 1:P.O. BOX 370602
Mailing Address - Street 2:12 CROSSROADS PLAZA
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117
Mailing Address - Country:US
Mailing Address - Phone:860-414-4787
Mailing Address - Fax:
Practice Address - Street 1:18 JUNIPER LANE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117
Practice Address - Country:US
Practice Address - Phone:860-414-4787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Single Specialty