Healthcare Provider Details

I. General information

NPI: 1629158126
Provider Name (Legal Business Name): CONNECTICUT BEHAVIORAL HEALTH ASSOC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 11/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 FAIR HARBOUR PL
NEW LONDON CT
06320-4710
US

IV. Provider business mailing address

41 FAIR HARBOUR PL
NEW LONDON CT
06320-4710
US

V. Phone/Fax

Practice location:
  • Phone: 860-437-6914
  • Fax: 860-437-6920
Mailing address:
  • Phone: 860-437-6914
  • Fax: 860-437-6920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. BASSAM AWWA
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 860-437-6914