Healthcare Provider Details

I. General information

NPI: 1174902084
Provider Name (Legal Business Name): CONNECTICUT PSYCHIATRIC & WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BRADLEY RD 404
WOODBRIDGE CT
06525-2285
US

IV. Provider business mailing address

1 BRADLEY RD SUITE 404
WOODBRIDGE CT
06525-2285
US

V. Phone/Fax

Practice location:
  • Phone: 203-298-9005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2422
License Number StateCT

VIII. Authorized Official

Name: DAVID AVERSA
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 203-298-9005