Healthcare Provider Details

I. General information

NPI: 1396516381
Provider Name (Legal Business Name): COLLABORATIVE CANCER CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 SPENCER ST STE 2
MANCHESTER CT
06040-4601
US

IV. Provider business mailing address

8 BIRCHWOOD RD
EAST HARTFORD CT
06118-1702
US

V. Phone/Fax

Practice location:
  • Phone: 860-245-8853
  • Fax:
Mailing address:
  • Phone: 617-650-3391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: WENDY GARVIN
Title or Position: NURSE PRACTITIONER
Credential: APRN
Phone: 617-650-3391