Provider Demographics
NPI:1144876392
Name:REDEEM WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:REDEEM WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:CULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-368-5515
Mailing Address - Street 1:6405 CAMDEN RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-7216
Mailing Address - Country:US
Mailing Address - Phone:910-275-5766
Mailing Address - Fax:833-596-0382
Practice Address - Street 1:3180 MAIN ST STE 106
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4237
Practice Address - Country:US
Practice Address - Phone:203-208-3940
Practice Address - Fax:203-372-3272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-14
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004069985Medicaid