Provider Demographics
NPI:1043094956
Name:INNERLIGHT WELLNESS COUNSELING PLLC
Entity type:Organization
Organization Name:INNERLIGHT WELLNESS COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:TIEDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:860-918-7946
Mailing Address - Street 1:119C GRISWOLD ST STE 202
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1099
Mailing Address - Country:US
Mailing Address - Phone:860-918-7946
Mailing Address - Fax:
Practice Address - Street 1:119C GRISWOLD ST STE 202
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1099
Practice Address - Country:US
Practice Address - Phone:860-918-7946
Practice Address - Fax:860-735-5842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty