Provider Demographics
NPI:1518001940
Name:SALAZAR, MAXIMILIANO
Entity Type:Individual
Prefix:MR
First Name:MAXIMILIANO
Middle Name:
Last Name:SALAZAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-1312
Mailing Address - Country:US
Mailing Address - Phone:860-229-8887
Mailing Address - Fax:860-229-8886
Practice Address - Street 1:55 WINTHROP ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1728
Practice Address - Country:US
Practice Address - Phone:860-224-8192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCAC 23841101YA0400X
CTSCCD 1201101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1174624423OtherCMHA FACILITY NPI
CT1942393814Medicaid
CT1942393814Medicaid