Provider Demographics
NPI:1487409116
Name:MESA PROFESSIONAL CO. LLC
Entity type:Organization
Organization Name:MESA PROFESSIONAL CO. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-578-8783
Mailing Address - Street 1:483 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118-2000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:483 FOREST ST
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118-2000
Practice Address - Country:US
Practice Address - Phone:860-578-8783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty