Provider Demographics
NPI:1902392103
Name:THERAPEUTIC WELLNESS, LLC
Entity Type:Organization
Organization Name:THERAPEUTIC WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CASPARIUS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:203-970-7896
Mailing Address - Street 1:25 BURR FARMS RD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-3818
Mailing Address - Country:US
Mailing Address - Phone:203-970-7896
Mailing Address - Fax:
Practice Address - Street 1:266 POST RD E
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-3625
Practice Address - Country:US
Practice Address - Phone:203-970-7896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002002106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004069985Medicaid