Provider Demographics
NPI:1639377328
Name:SHORELINE PSYCHIATRY OF WESTERN CONNECTICUT, LLC
Entity Type:Organization
Organization Name:SHORELINE PSYCHIATRY OF WESTERN CONNECTICUT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BART
Authorized Official - Middle Name:A
Authorized Official - Last Name:SLOAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-656-1452
Mailing Address - Street 1:20 OLD KINGS HWY S
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:DARIEN
Mailing Address - State:CT
Mailing Address - Zip Code:06820-4521
Mailing Address - Country:US
Mailing Address - Phone:203-656-1452
Mailing Address - Fax:203-656-1485
Practice Address - Street 1:20 OLD KINGS HWY S
Practice Address - Street 2:2ND FLOOR
Practice Address - City:DARIEN
Practice Address - State:CT
Practice Address - Zip Code:06820-4521
Practice Address - Country:US
Practice Address - Phone:203-656-1452
Practice Address - Fax:203-656-1485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherFEDERAL TAX ID NUMBER