Provider Demographics
NPI:1487079885
Name:BRAIN MIND BODY PSYCHOTHERAPY, LLC
Entity type:Organization
Organization Name:BRAIN MIND BODY PSYCHOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAGA-ZAPF
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-293-4395
Mailing Address - Street 1:6 STEEP HILL RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:CT
Mailing Address - Zip Code:06883-1731
Mailing Address - Country:US
Mailing Address - Phone:203-557-0305
Mailing Address - Fax:
Practice Address - Street 1:177 POST RD W STE 1
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4652
Practice Address - Country:US
Practice Address - Phone:203-293-4395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-22
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
CT0082021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty