Healthcare Provider Details

I. General information

NPI: 1730442179
Provider Name (Legal Business Name): WBC CONNECTICUT EAST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 TAMARACK AVE SUITE 203
SOUTH WINDSOR CT
06074-5555
US

IV. Provider business mailing address

880 MAIN ST
WALTHAM MA
02451-8500
US

V. Phone/Fax

Practice location:
  • Phone: 860-533-4672
  • Fax: 860-533-4673
Mailing address:
  • Phone: 781-647-6767
  • Fax: 781-647-6755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. STUART KOMAN
Title or Position: CEO / OWNER
Credential: PHD
Phone: 781-647-6701