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General NPI Number Information
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NPI Number | 1962760561
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Entity Type | Organization
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Legal Business Name | WELLMORE, INC
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Dates
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Enumeration Date | 05/02/2012
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Last Update Date | 08/23/2016
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Provider Practice Location Address
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Address Line | 402 EAST MAIN ST WATERBURY OUTPATIENT BEHAVIORAL HEALTH SERVICES
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City | WATERBURY
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State | CT
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Zip | 06702-1701
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Country | US
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Telephone | 203-755-1143
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Fax | 203-753-3274
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Provider Business Mailing Address
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Address Line | 141 E MAIN ST 4TH FLOOR ADMINISTRATION
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City | WATERBURY
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State | CT
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Zip | 06702-2310
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Country | US
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Telephone | 203-574-9000
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Fax | 203-574-9006
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MR. GARY M STECK
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Credential | LMFT
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Telephone | 203-574-9000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | DPH 0436/0528
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License Number State | CT
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