Mystic Medical Associates LLC

Primary specialty

Primary Care Clinic/CenterTaxonomy code 261QP2300X

Legal business name

MYSTIC MEDICAL ASSOCIATES LLC

Practice address

12 Roosevelt Ave
Second Floor
Mystic, CT 06355-2809

Phone

(860) 245-4126

Fax

(860) 245-4128

NPI assigned

Jun 27, 2016

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Christopher J Anderson, MSN FNP-C

Title

Aprn

Phone

(860) 245-4126

Specialties & licenses 2

Addresses

Locations

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Jeannine Cleaver, LCSW

  • Clinical Social Worker
  • Mystic, CT
  • NPI 1336591924
  NPD
• Yasmin Fabian, MA

  • Clinical Social Worker
  • New London, CT
  • NPI 1508334822
  NPD
• Tara Lynne Sousa, MFTA

  • Marriage & Family Therapist
  • New London, CT
  • NPI 1073193223
  NPD
• Shaina Dawn Wilkinson, MSW, LMSW,LCSW

  • Clinical Social Worker
  • Mystic, CT
  • NPI 1316340334
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1466985600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1710979200000",
    "number": "1972954477",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "495 GOLD STAR HWY STE 112",
            "city": "GROTON",
            "state": "CT",
            "postal_code": "063406229",
            "telephone_number": "860-245-4126",
            "fax_number": "860-245-4128"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12 ROOSEVELT AVE",
            "address_2": "SECOND FLOOR",
            "city": "MYSTIC",
            "state": "CT",
            "postal_code": "063552809",
            "telephone_number": "860-245-4126",
            "fax_number": "860-245-4128"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "230 S Main St.",
            "address_2": "Suite #2",
            "address_purpose": "LOCATION",
            "city": "Cheshire",
            "state": "CT",
            "postal_code": "064100641",
            "country_code": "US",
            "telephone_number": "860-245-4126",
            "fax_number": "877-927-0171",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "MYSTIC MEDICAL ASSOCIATES LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-06-27",
        "last_updated": "2024-03-21",
        "certification_date": "2024-03-21",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "CHRISTOPHER",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "APRN",
        "authorized_official_telephone_number": "860-245-4126",
        "authorized_official_credential": "MSN FNP-C"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Mystic Bridge to Wellness, LLC
• Mystic Dental Group, P.C.
• Mystic Geriatrics, LLC
• Mystic Healthcare & Rehabilitation Center LLC
• Mystic Healthcare and Rehabilitation Facility
• Mystic Medical Group, PC
• Mystic River Ambulance Association, Inc
• Mystic Services, LLC
• Mystic Spine & Sport LLC
• Mystic Therapy, LLC.

• Primary Care Clinic/Center in Mystic, CT
• Providers in Mystic, CT by specialty
• Primary Care Clinic/Center in Connecticut

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 21, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.