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?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty