Healthcare Provider Details

I. General information

NPI: 1164749057
Provider Name (Legal Business Name): DR OVANESSIAN TREATMENT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2010
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 CHURCH HILL RD
NEWTOWN CT
06470-1657
US

IV. Provider business mailing address

20 CHURCH HILL RD
NEWTOWN CT
06470-1657
US

V. Phone/Fax

Practice location:
  • Phone: 203-304-9599
  • Fax:
Mailing address:
  • Phone: 203-304-9559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number042079
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number042079
License Number StateCT

VIII. Authorized Official

Name: DR. SIMON OVANESSAIN
Title or Position: PHYSICIAN/SURGEON
Credential: M.D.
Phone: 845-548-6073