Provider Demographics
NPI:1154901973
Name:FAITHWELL COUNSELING AND SERVICES, LLC.
Entity type:Organization
Organization Name:FAITHWELL COUNSELING AND SERVICES, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MIREILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAINES
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-314-4695
Mailing Address - Street 1:1204 MAIN ST STE 512
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3787
Mailing Address - Country:US
Mailing Address - Phone:678-314-4695
Mailing Address - Fax:203-481-7634
Practice Address - Street 1:1204 MAIN ST STE 512
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3787
Practice Address - Country:US
Practice Address - Phone:678-314-4695
Practice Address - Fax:203-481-7634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-14
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1154901973Medicaid
CT1861040065Medicaid