Provider Demographics
NPI:1003145582
Name:NATCHAUG HOSPITAL
Entity Type:Organization
Organization Name:NATCHAUG HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRIMARY THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:860-963-6416
Mailing Address - Street 1:42 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-5404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:320 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1836
Practice Address - Country:US
Practice Address - Phone:860-963-6416
Practice Address - Fax:860-963-6303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-13
Last Update Date:2009-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001670324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001670OtherDEPARTMENT OF PUBLIC HEALTH