Healthcare Provider Details

I. General information

NPI: 1710312368
Provider Name (Legal Business Name): CONNECTICUT ADDICTION MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2013
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 CROMWELL AVE SUITE 101
ROCKY HILL CT
06067-1800
US

IV. Provider business mailing address

546 CROMWELL AVE SUITE 101
ROCKY HILL CT
06067-1800
US

V. Phone/Fax

Practice location:
  • Phone: 860-757-3874
  • Fax: 860-757-3875
Mailing address:
  • Phone: 860-757-3874
  • Fax: 860-757-3875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberCLPOL0509
License Number StateCT
# 8
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number StateCT
# 9
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY INGOLD
Title or Position: OFFICE MANAGER
Credential: OFFICE MANAGER
Phone: 860-969-1101