Provider Demographics
NPI:1972266591
Name:MYSTIC RIVER THERAPY LLC
Entity Type:Organization
Organization Name:MYSTIC RIVER THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDING OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DRUGAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:860-304-3503
Mailing Address - Street 1:141 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-4055
Mailing Address - Country:US
Mailing Address - Phone:860-304-3503
Mailing Address - Fax:
Practice Address - Street 1:112 NEW LONDON RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4869
Practice Address - Country:US
Practice Address - Phone:860-304-3503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-20
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty