MEDICARE: RISE UP BEHAVIORAL HEALTH SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1588215156
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RISE UP BEHAVIORAL HEALTH SERVICES LLC

Provider Business Mailing Address
First Line	:	84 PORTLAND ST
Second Line	:
City	:	OAKVILLE
State	:	CT
Zip	:	06779-1032
Country	:	US
Telephone Number	:	203-217-1455
Fax Number	:

Provider Business Practice Location Address
First Line	:	76 WESTBURY PARK RD
Second Line	:
City	:	WATERTOWN
State	:	CT
Zip	:	06795-2779
Country	:	US
Telephone Number	:	860-484-3781
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	HEATHER HUMPHREY
Credential	:	APRN
Telephone Number	:	203-217-1455

Provider Enumeration Date	:	09/25/2019
Last Update Date	:	09/25/2019

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