1881002368 NPI number — EMILY A RANDALL LCSW

Table of content: STEPHANIE MARIE PREWITT PSS (NPI 1720824055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881002368 NPI number — EMILY A RANDALL LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANDALL
Provider First Name:
EMILY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881002368
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 OLD NEW MILFORD ROAD
Provider Second Line Business Mailing Address:
SUITE 1-B
Provider Business Mailing Address City Name:
BROOKFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-775-2583
Provider Business Mailing Address Fax Number:
203-775-2863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
141 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06702-2310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-574-9000
Provider Business Practice Location Address Fax Number:
203-574-9006
Provider Enumeration Date:
07/28/2014

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: 104100000X , with the licence number:  2218 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 060669107 . This is a "HEALTHYCT WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "UBH-UNITED HEALTHCARE WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "UBH-CONNECTICARE WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 13671806 . This is a "CAQH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060669107 . This is a "ANTHEM BEHAVIORRAL HEALTH WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "OPTUM BEHAVIORAL HEALTH/UBH WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: NOT ELIGIBLE . This is a "BEACON HEALTH STRATEGIES" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "UBH-OXFORD FREEDOM/LIBERTY WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "AETNA BEHAVIORAL HEALTH WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: NOT ELIGIBLE . This is a "MHN TRICARE NORTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING . This is a "CIGNA BEHAVIORAL HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: NOT ELIGIBLE . This is a "MHN-MANAGED HEALTH NETWORK" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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