Healthcare Provider Details

I. General information

NPI: 1316161193
Provider Name (Legal Business Name): WATERBURY PSYCHIATRIC ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 SCOVILL ST SUITE # 201
WATERBURY CT
06706-1127
US

IV. Provider business mailing address

133 SCOVILL ST SUITE # 201
WATERBURY CT
06706-1127
US

V. Phone/Fax

Practice location:
  • Phone: 203-597-0575
  • Fax: 203-757-4105
Mailing address:
  • Phone: 203-597-0575
  • Fax: 203-757-4105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number042814
License Number StateCT

VIII. Authorized Official

Name: AZHAR IMAM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 203-597-0575