=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164292512
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTUM BEHAVIORAL CARE OF CONNECTICUT, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2024
-----------------------------------------------------
Last Update Date | 01/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 CUMMINGS CTR STE 456J
-----------------------------------------------------
City | BEVERLY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01915-6132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-296-3460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 67 BURNSIDE AVE
-----------------------------------------------------
City | EAST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06108-3408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-506-6267
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | AMANDA STACEY BRONSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 978-222-3121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------