Provider Demographics
NPI:1245430891
Name:INTERCOMMUNITY MENTAL HEALTH GROUP
Entity Type:Organization
Organization Name:INTERCOMMUNITY MENTAL HEALTH GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF ADMINISTRATION
Authorized Official - Prefix:MR
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:
Authorized Official - Last Name:GAINES
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CPA
Authorized Official - Phone:860-895-2308
Mailing Address - Street 1:281 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118-1823
Mailing Address - Country:US
Mailing Address - Phone:860-569-5900
Mailing Address - Fax:
Practice Address - Street 1:505 SILAS DEANE HWY
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-2216
Practice Address - Country:US
Practice Address - Phone:860-569-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTC-0109261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT312837OtherMHN
CT312837OtherMHN
CT312837OtherMHN