Provider Demographics
NPI:1538382049
Name:INTEGRATIVE MEDICINE AND PSYCHOTHERAPY OF GREENWICH LLC
Entity type:Organization
Organization Name:INTEGRATIVE MEDICINE AND PSYCHOTHERAPY OF GREENWICH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEVRA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BRAUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-622-2394
Mailing Address - Street 1:360 WEST PUTNAM AVENUE
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830
Mailing Address - Country:US
Mailing Address - Phone:203-622-2394
Mailing Address - Fax:203-622-2396
Practice Address - Street 1:360 WEST PUTNAM AVENUE
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830
Practice Address - Country:US
Practice Address - Phone:203-622-2394
Practice Address - Fax:203-622-2396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1710492084P0800X
CT0026692084P0800X
CT0353182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F36071Medicare UPIN