Provider Demographics
NPI:1457636383
Name:SPECTRUM BEHAVIORAL PC
Entity Type:Organization
Organization Name:SPECTRUM BEHAVIORAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNIL
Authorized Official - Middle Name:
Authorized Official - Last Name:SAXENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-612-7511
Mailing Address - Street 1:30 BUXTON FARM RD
Mailing Address - Street 2:SUITE140
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-1224
Mailing Address - Country:US
Mailing Address - Phone:203-612-7512
Mailing Address - Fax:203-930-3655
Practice Address - Street 1:30 BUXTON FARM RD
Practice Address - Street 2:SUITE140
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-1224
Practice Address - Country:US
Practice Address - Phone:203-612-7512
Practice Address - Fax:203-930-3655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-11
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3117103TC1900X
CT0437232084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI52047Medicare UPIN