Provider Demographics
NPI:1124524798
Name:IMAGE OF LIGHT MENTAL HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:IMAGE OF LIGHT MENTAL HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:860-299-6677
Mailing Address - Street 1:53 BURNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-2235
Mailing Address - Country:US
Mailing Address - Phone:860-299-6677
Mailing Address - Fax:
Practice Address - Street 1:45 S MAIN ST STE 70
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107
Practice Address - Country:US
Practice Address - Phone:860-299-6677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-03
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty