Healthcare Provider Details

I. General information

NPI: 1972954477
Provider Name (Legal Business Name): MYSTIC MEDICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 ROOSEVELT AVE SECOND FLOOR
MYSTIC CT
06355-2809
US

IV. Provider business mailing address

495 GOLD STAR HWY STE 112
GROTON CT
06340-6229
US

V. Phone/Fax

Practice location:
  • Phone: 860-245-4126
  • Fax: 860-245-4128
Mailing address:
  • Phone: 860-245-4126
  • Fax: 860-245-4128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHRISTOPHER J ANDERSON
Title or Position: APRN
Credential: MSN FNP-C
Phone: 860-245-4126