Healthcare Provider Details

I. General information

NPI: 1245627801
Provider Name (Legal Business Name): MICHAEL DIBIASE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 SILAS DEANE HWY
WETHERSFIELD CT
06109-1219
US

IV. Provider business mailing address

100 GRAND ST FL 1
NEW BRITAIN CT
06052-2016
US

V. Phone/Fax

Practice location:
  • Phone: 860-222-0840
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number63949
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: