Provider Demographics
NPI:1467010116
Name:PRIMAL MENTAL AND PHYSICAL HEALTH
Entity Type:Organization
Organization Name:PRIMAL MENTAL AND PHYSICAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-456-7335
Mailing Address - Street 1:54 BELLEVUE TER
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:CT
Mailing Address - Zip Code:06483-3202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:
Practice Address - City:OAKVILLE
Practice Address - State:CT
Practice Address - Zip Code:06779-1999
Practice Address - Country:US
Practice Address - Phone:203-456-7335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty