1285705509 NPI number — DR. KELLY TAHANEY WEBER PSYD

Table of content: DR. KELLY TAHANEY WEBER PSYD (NPI 1285705509)

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".