1285705509 NPI number — DR. KELLY TAHANEY WEBER PSYD

Table of content: JINHEE KIM (NPI 1932659083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285705509 NPI number — DR. KELLY TAHANEY WEBER PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEBER
Provider First Name:
KELLY
Provider Middle Name:
TAHANEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TAHANEY
Provider Other First Name:
KELLY
Provider Other Middle Name:
DALE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSYD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1285705509
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
174 N QUAKER LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-236-1695
Provider Business Mailing Address Fax Number:
860-236-1695

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 HEBRON AVENUE
Provider Second Line Business Practice Location Address:
SUITE 217 MEDICAL ARTS CENTER COUNSELING AFFILIATES
Provider Business Practice Location Address City Name:
GLASTONBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-659-2697
Provider Business Practice Location Address Fax Number:
860-659-3468
Provider Enumeration Date:
11/10/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  002358 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11518434 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".