Healthcare Provider Details

I. General information

NPI: 1588604060
Provider Name (Legal Business Name): MEDOPTIONS BEHAVIORAL HEALTH ASSOC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 05/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 RESEARCH PKWY SUITE C
OLD SAYBROOK CT
06475-4214
US

IV. Provider business mailing address

20 RESEARCH PKWY SUITE C
OLD SAYBROOK CT
06475-4214
US

V. Phone/Fax

Practice location:
  • Phone: 800-370-3651
  • Fax: 860-510-0020
Mailing address:
  • Phone: 800-370-3651
  • Fax: 860-510-0020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRENDA DE GRAY
Title or Position: CREDENTIALING MNGR
Credential:
Phone: 800-370-3651