Provider Demographics
NPI:1578774113
Name:CONNECTICUT BEHAVIORAL HEALTH ASSOC. P.C.
Entity Type:Organization
Organization Name:CONNECTICUT BEHAVIORAL HEALTH ASSOC. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN.
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-437-6914
Mailing Address - Street 1:41 FAIR HARBOUR PL
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4710
Mailing Address - Country:US
Mailing Address - Phone:860-437-6910
Mailing Address - Fax:860-437-6920
Practice Address - Street 1:41 FAIR HARBOUR PL
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4710
Practice Address - Country:US
Practice Address - Phone:860-437-6910
Practice Address - Fax:860-437-6920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004255388OtherST OF CONN GRP #S SCWKRS)