=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730694316
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPACT HEALTH P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2017
-----------------------------------------------------
Last Update Date | 07/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 WESTPORT AVE
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | --
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14 WESTPORT AVE
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06851-3915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | --
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED PERSON
-----------------------------------------------------
Name | GARUMUNI A. DESILVA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 203-988-0766
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TB0200X
-----------------------------------------------------
Taxonomy Name | Cognitive & Behavioral Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #11
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #12
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #13
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------