1962760561 NPI number — WELLMORE, INC

Table of content: (NPI 1962760561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962760561 NPI number — WELLMORE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLMORE, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WELLMORE, INC.-WATERBURY OP BEHAVIORAL HEALTH SERVICES
Provider Other Organization Name Type Code:
3
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:
1962760561
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
141 E MAIN ST
Provider Second Line Business Mailing Address:
4TH FLOOR ADMINISTRATION
Provider Business Mailing Address City Name:
WATERBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06702-2310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-574-9000
Provider Business Mailing Address Fax Number:
203-574-9006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 EAST MAIN ST
Provider Second Line Business Practice Location Address:
WATERBURY OUTPATIENT BEHAVIORAL HEALTH SERVICES
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06702-1701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-755-1143
Provider Business Practice Location Address Fax Number:
203-753-3274
Provider Enumeration Date:
05/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
STECK
Authorized Official First Name:
GARY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
203-574-9000

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  DPH 0436/0528 , 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: GRP/FACILITY . This is a "UBH/OXFORD-FREEDOM HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 008040528 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: GRP/FACILITY . This is a "ANTHEM BCBS OF CT" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: GRP/FACILITY . This is a "UBH-CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: D339210 . This is a "BEACON HEALTH STRATEGIES" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: GRP/FACILITY . This is a "UBH-UNITED HEALTHCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: GRP/FACILITY . This is a "MHN/MHN TRICARE NORTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: GRP/FACILITY . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: GRP/FACILITY . This is a "OPTUM BEHAVIORAL HEALTH/UBH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0528 . This is a "DPH-PSYCHIATRIC OUTPATIENT CLINIC FOR ADULTS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 7882859 . This is a "AETNA HEALTH PLAN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: GRP/FACILITY . This is a "HEALTHYCT" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: LICENSE NO. 0436 . This is a "DPH-FACILITY FOR THE CARE OR TREATMENT OF SUBSTANCE ABUSE OR DEPENDENT PERSONS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2266871 . This is a "CIGNA BEHAVIORAL HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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