Healthcare Provider Details

I. General information

NPI: 1245016005
Provider Name (Legal Business Name): CONNECTICUT CENTER FOR PSYCHIATRIC WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2023
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 SHERMAN AVENUE
NEW HAVEN CT
06511-5238
US

IV. Provider business mailing address

92 MACINTOSH WAY C/O ERIC W. VOIDE
SOUTHINGTON CT
06489-2055
US

V. Phone/Fax

Practice location:
  • Phone: 203-565-5104
  • Fax: 860-826-4762
Mailing address:
  • Phone: 203-565-5104
  • Fax: 860-826-4762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ERIC W. VOIDE
Title or Position: CEO
Credential:
Phone: 203-565-5104