Provider Demographics
NPI:1295130581
Name:MINDSCAPES COUNSELING PLLC
Entity type:Organization
Organization Name:MINDSCAPES COUNSELING PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, SECRETARY, AND TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:ELLIOT
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-605-4986
Mailing Address - Street 1:230 FROST RD UNIT B
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-2154
Mailing Address - Country:US
Mailing Address - Phone:203-768-4427
Mailing Address - Fax:
Practice Address - Street 1:230 FROST RD UNIT B
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-2154
Practice Address - Country:US
Practice Address - Phone:203-819-0789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REFRESH MENTAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-29
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 261QM0801X
CT0080641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008056440Medicaid