Provider Demographics
NPI:1629158126
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:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BASSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:AWWA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
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:860-437-6914
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:860-437-6914
Practice Address - Fax:860-437-6920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004192324Medicaid
CT004255388Medicaid
CT008008065Medicaid
CT004199271Medicaid
CT004255411Medicaid
CT004195774Medicaid
CT004255388Medicaid