Healthcare Provider Details

I. General information

NPI: 1063644391
Provider Name (Legal Business Name): VICTOR TIRADO MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 SILAS DEANE HWY 2ND FLOOR WEST
WETHERSFIELD CT
06109-4220
US

IV. Provider business mailing address

929 SILAS DEANE HWY 2ND FLOOR WEST
WETHERSFIELD CT
06109-4220
US

V. Phone/Fax

Practice location:
  • Phone: 860-372-4731
  • Fax: 860-372-4730
Mailing address:
  • Phone: 860-372-4731
  • Fax: 860-372-4730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number042939
License Number StateCT

VIII. Authorized Official

Name: VICTOR TIRADO-MONTANEZ
Title or Position: OWNER
Credential: MD
Phone: 860-372-4731