Provider Demographics
NPI:1477999340
Name:STAYWELL HEALTH CARE INC.
Entity Type:Organization
Organization Name:STAYWELL HEALTH CARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ESTRADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-756-8021
Mailing Address - Street 1:80 PHOENIX AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-1418
Mailing Address - Country:US
Mailing Address - Phone:203-756-8021
Mailing Address - Fax:203-596-9038
Practice Address - Street 1:1309 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1758
Practice Address - Country:US
Practice Address - Phone:203-597-9044
Practice Address - Fax:203-596-9038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-17
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT05061041C0700X
CT0474261QF0400X
CT0479261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235968Medicaid
CTC00415Medicare PIN