1811363062 NPI number — DR. MIRYAM WELBOURNE PSY.D.

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 1811363062 NPI number — DR. MIRYAM WELBOURNE PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WELBOURNE
Provider First Name:
MIRYAM
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WELBOURNE
Provider Other First Name:
MIRYAM
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSY.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1811363062
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 STRICKLAND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLEFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06455-1225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-836-1794
Provider Business Mailing Address Fax Number:
888-600-3738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
363 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06457-3359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-836-1794
Provider Business Practice Location Address Fax Number:
888-600-3738
Provider Enumeration Date:
08/11/2015

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 3491 , 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: 008061424 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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