Provider Demographics
NPI:1336900901
Name:MISFIT MAMAS, INC.
Entity Type:Organization
Organization Name:MISFIT MAMAS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOBIERAJ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:310-991-0939
Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-0629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 LAKE AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-7318
Practice Address - Country:US
Practice Address - Phone:860-222-0831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-19
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty