1245016005 NPI number — CONNECTICUT CENTER FOR PSYCHIATRIC WELLNESS LLC

Table of content: (NPI 1245016005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245016005 NPI number — CONNECTICUT CENTER FOR PSYCHIATRIC WELLNESS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONNECTICUT CENTER FOR PSYCHIATRIC WELLNESS LLC
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:
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:
1245016005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
92 MACINTOSH WAY
Provider Second Line Business Mailing Address:
C/O ERIC W. VOIDE
Provider Business Mailing Address City Name:
SOUTHINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06489-2055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-565-5104
Provider Business Mailing Address Fax Number:
860-826-4762

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
136 SHERMAN AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06511-5238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-565-5104
Provider Business Practice Location Address Fax Number:
860-826-4762
Provider Enumeration Date:
09/06/2023

Additional Information

Authorized Official

Authorized Official Last Name:
VOIDE
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
203-565-5104

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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