Provider Demographics
NPI:1427849355
Name:TRAILHEAD THERAPY LLC
Entity type:Organization
Organization Name:TRAILHEAD THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIA WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:RAQUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW: LICENSE 2489
Authorized Official - Phone:646-342-4197
Mailing Address - Street 1:2389 MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4617
Mailing Address - Country:US
Mailing Address - Phone:646-342-4197
Mailing Address - Fax:
Practice Address - Street 1:2389 MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4617
Practice Address - Country:US
Practice Address - Phone:646-342-4197
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-12
Last Update Date:2025-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty