Provider Demographics
NPI:1811363062
Name:WELBOURNE, MIRYAM (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MIRYAM
Middle Name:
Last Name:WELBOURNE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MIRYAM
Other - Middle Name:
Other - Last Name:WELBOURNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:104 STRICKLAND RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06455-1225
Mailing Address - Country:US
Mailing Address - Phone:203-836-1794
Mailing Address - Fax:888-600-3738
Practice Address - Street 1:363 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3359
Practice Address - Country:US
Practice Address - Phone:203-836-1794
Practice Address - Fax:888-600-3738
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-11
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
CT3491103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008061424Medicaid