Provider Demographics
NPI: | 1376692111 |
---|---|
Name: | PSYCHIATRIC MEDICINE CENTER, PC |
Entity Type: | Organization |
Organization Name: | PSYCHIATRIC MEDICINE CENTER, PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CREDENTIALER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | PAMELA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | GRAVES |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 860-442-6364 |
Mailing Address - Street 1: | 501 OCEAN AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | NEW LONDON |
Mailing Address - State: | CT |
Mailing Address - Zip Code: | 06320-4521 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 860-442-6364 |
Mailing Address - Fax: | 860-447-9977 |
Practice Address - Street 1: | 501 OCEAN AVE |
Practice Address - Street 2: | |
Practice Address - City: | NEW LONDON |
Practice Address - State: | CT |
Practice Address - Zip Code: | 06320-4521 |
Practice Address - Country: | US |
Practice Address - Phone: | 860-442-6364 |
Practice Address - Fax: | 860-447-9977 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-01-10 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health | Group - Single Specialty |