Basic Information
| Provider Information | |||||||||
| NPI: | 1629494232 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TR COUNSELING & WELLNESS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 SHAWMUT AVE | ||||||||
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| City: | NORTH HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064732660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038197650 | ||||||||
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| Practice Location | |||||||||
| Address1: | 30 HAZEL TERRACE | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | WOODBRIDGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065252240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038197650 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2014 | ||||||||
| LastUpdateDate: | 04/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | REILLY | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 2038197650 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPC LADC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 000951 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 002448 | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 008038188 | 05 | CT | MEDICAID |