Healthcare Provider Details

I. General information

NPI: 1982645669
Provider Name (Legal Business Name): COMMUNITY HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 MAIN ST
MIDDLETOWN CT
06457-2718
US

IV. Provider business mailing address

635 MAIN ST ATTN: CREDENTIALING DEPARTMENT
MIDDLETOWN CT
06457-2718
US

V. Phone/Fax

Practice location:
  • Phone: 860-347-6971
  • Fax: 860-638-6601
Mailing address:
  • Phone: 860-347-6971
  • Fax: 860-638-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0394
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberOPCC23
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0394
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0394
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberOPCC23
License Number StateCT
# 6
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MS. BAIN PATRIE
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 860-347-6971