Provider Demographics
NPI:1164749057
Name:DR OVANESSIAN TREATMENT CENTER LLC
Entity Type:Organization
Organization Name:DR OVANESSIAN TREATMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:OVANESSAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-548-6073
Mailing Address - Street 1:20 CHURCH HILL RD
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-1657
Mailing Address - Country:US
Mailing Address - Phone:203-304-9559
Mailing Address - Fax:
Practice Address - Street 1:20 CHURCH HILL RD
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-1657
Practice Address - Country:US
Practice Address - Phone:203-304-9599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-01
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0420792084P0802X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Single Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Single Specialty