Healthcare Provider Details

I. General information

NPI: 1366115552
Provider Name (Legal Business Name): WILDWOOD BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 DURHAM RD STE F
MADISON CT
06443-8015
US

IV. Provider business mailing address

1250 DURHAM RD STE F
MADISON CT
06443-8015
US

V. Phone/Fax

Practice location:
  • Phone: 203-421-6372
  • Fax: 203-421-2090
Mailing address:
  • Phone: 203-421-6372
  • Fax: 203-421-2090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW GALLUP
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 617-905-1269