Healthcare Provider Details

I. General information

NPI: 1992781488
Provider Name (Legal Business Name): MASONICARE BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 06/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 MASONIC AVE 1ST FLOOR
WALLINGFORD CT
06492-3095
US

IV. Provider business mailing address

67 MASONIC AVE 1ST FLOOR
WALLINGFORD CT
06492-3095
US

V. Phone/Fax

Practice location:
  • Phone: 203-265-5720
  • Fax: 203-679-5623
Mailing address:
  • Phone: 203-265-5720
  • Fax: 203-679-5623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN TIBBETTS
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 203-265-5720