Provider Demographics
NPI:1578819884
Name:ALI, TABASSUM A (APRN)
Entity Type:Individual
Prefix:
First Name:TABASSUM
Middle Name:A
Last Name:ALI
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:141 E MAIN ST
Mailing Address - Street 2:4TH FLOOR ADMINISTATION
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-2310
Mailing Address - Country:US
Mailing Address - Phone:203-574-9000
Mailing Address - Fax:203-574-9006
Practice Address - Street 1:141 E MAIN ST
Practice Address - Street 2:WATERBURY CLINICIAL SERVICES 2ND FLOOR
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702
Practice Address - Country:US
Practice Address - Phone:855-935-5667
Practice Address - Fax:203-596-0722
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT98808163W00000X
CTANCC2012007952163WP0807X
CT005035363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060669107OtherUBH-UNITED BEHAVIORAL HEALTH NETWORK WELLMORE GRP/FACILITY
12671467OtherCAQH
CT507335OtherMHN/MANAGED HEALTH NETWORK
CTCSP.0053391OtherCONTROLLED SUBSTANCE LICENSE
CT4853955OtherCIGNA BEHAVIORAL HEALTH
CT9777891OtherAETNA BEHAVIORAL HEALTH
CT060669107OtherHCT-HEALTHY CT WELLMORE GRP/FACILITY CONTRACT
CT060669107OtherUBH-UNITED HEALTHCARE WELLMORE GRP/FACILITY
CT507335OtherTRICARE NORTH
CT060669107OtherANTHEM BCBS OF CT BEHAVIORAL HEALTH-WELLMORE GRP/FACILITY
CT008042033Medicaid
CTD339209 WATERBURYOtherVALUE OPTIONS/BEACON HEALTH STRATEGIES
CT060669107OtherUBH-OXFORD HEALTH/LIBERTY GRP/FACILITY
CTCSP.0053391OtherCONTROLLED SUBSTANCE REGISTRATION FOR PRACTITIONER
CTCSP.0053391OtherCONTROLLED SUBSTANCE REGISTRATION FOR PRACTITIONER
CT060669107OtherUBH-UNITED BEHAVIORAL HEALTH NETWORK WELLMORE GRP/FACILITY
CTCSP.0053391OtherCONTROLLED SUBSTANCE REGISTRATION FOR PRACTITIONER