1598260226 NPI number — SUPPORTIVE SOLUTIONS BEHAVIORAL HEALTH AND WELLNESS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598260226 NPI number — SUPPORTIVE SOLUTIONS BEHAVIORAL HEALTH AND WELLNESS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPPORTIVE SOLUTIONS BEHAVIORAL HEALTH AND 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:
1598260226
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
49 ENGLEWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06515-2309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2911 DIXWELL AVE STE 302
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMDEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06518-3130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-376-0220
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/26/2018

Additional Information

Authorized Official

Authorized Official Last Name:
ROSE
Authorized Official First Name:
SHALYN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/LCSW
Authorized Official Telephone Number:
203-376-0220

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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