Healthcare Provider Details

I. General information

NPI: 1245430891
Provider Name (Legal Business Name): INTERCOMMUNITY MENTAL HEALTH GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 SILAS DEANE HWY
WETHERSFIELD CT
06109-2216
US

IV. Provider business mailing address

281 MAIN ST
EAST HARTFORD CT
06118-1823
US

V. Phone/Fax

Practice location:
  • Phone: 860-569-5900
  • Fax:
Mailing address:
  • Phone: 860-569-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberC-0109
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier312837
Identifier TypeOTHER
Identifier StateCT
Identifier IssuerMHN

VIII. Authorized Official

Name: MR. MARSHALL GAINES
Title or Position: VICE PRESIDENT OF ADMINISTRATION
Credential: MBA, CPA
Phone: 860-895-2308