Healthcare Provider Details

I. General information

NPI: 1154342335
Provider Name (Legal Business Name): STAYWELL HEALTH CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 PHOENIX AVE
WATERBURY CT
06702-1418
US

IV. Provider business mailing address

80 PHOENIX AVE SUITE 201
WATERBURY CT
06702-1418
US

V. Phone/Fax

Practice location:
  • Phone: 203-756-8021
  • Fax: 203-596-9038
Mailing address:
  • Phone: 203-756-8021
  • Fax: 203-596-9038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number0360
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number0736
License Number StateCT
# 6
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCT

VIII. Authorized Official

Name: DONALD THOMPSON
Title or Position: PRESIDENT & CEO
Credential:
Phone: 203-756-8021