Healthcare Provider Details

I. General information

NPI: 1851629497
Provider Name (Legal Business Name): NORTHEAST BEHAVIORAL ASSOCIATES OF CT. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2009
Last Update Date: 07/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

769 NEWFIELD ST STE 5
MIDDLETOWN CT
06457-1846
US

IV. Provider business mailing address

68 HEBRON AVE
ATTLEBORO MA
02703-7241
US

V. Phone/Fax

Practice location:
  • Phone: 860-754-7735
  • Fax:
Mailing address:
  • Phone: 781-929-0553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-01-0652
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER C. PATCH
Title or Position: EXECUTIVE DIRECTOR
Credential: PSYD
Phone: 860-754-7735