MEDICARE: WELLMORE, INC.

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center	OPCC-11	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GRP/FACILITY	OTHER	CT	ANTHEM BCBS OF CT
2	GRP/FACILITY	OTHER	CT	MHN/MHN TRICARE NORTH
3	GRP/FACILITY	OTHER	CT	UBH-CONNECTICARE
4	GRP/FACILITY	OTHER	CT	OPTUM BEHAVIORAL HEALTH
5	4491935	OTHER	CT	CIGNA BEHAVIORAL HEALTH
6	D339123 WATERBURY	OTHER	CT	BECON HEALTH STRATEGIES
7	GRP/FACILITY	OTHER	CT	HEALTHYCT
8	GRP/FACILITY	OTHER	CT	UBH-OXFORD/FREEDOM
9	GRP/FACILITY	OTHER	CT	UBH/UNITED HEALTHCARE
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	9211645	OTHER	CT	AETNA HEALTH

General Provider Information

NPI Number	:	1841379013
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLMORE, INC.

Provider Business Mailing Address
First Line	:	141 E MAIN ST
Second Line	:
City	:	WATERBURY
State	:	CT
Zip	:	06702-2310
Country	:	US
Telephone Number	:	203-574-9000
Fax Number	:	203-574-9006

Provider Business Practice Location Address
First Line	:	141 E MAIN ST
Second Line	:
City	:	WATERBURY
State	:	CT
Zip	:	06702-2310
Country	:	US
Telephone Number	:	203-756-7287
Fax Number	:	203-596-0722

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. GARY STECK
Credential	:	LMFT
Telephone Number	:	203-756-7287

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	08/23/2016

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1639220387 — MR. LOUIS VINCENT VISCOSI III MS LPC
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Directions to “WELLMORE, INC. ” Practice Location

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