Provider Demographics
NPI:1891872842
Name:BEACON BEHAVIORAL SERVICES LLC
Entity Type:Organization
Organization Name:BEACON BEHAVIORAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:KUILAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-676-9350
Mailing Address - Street 1:433 S MAIN ST STE 327
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-2816
Mailing Address - Country:US
Mailing Address - Phone:860-676-9350
Mailing Address - Fax:860-678-7178
Practice Address - Street 1:40 DALE ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06000
Practice Address - Country:US
Practice Address - Phone:860-676-9350
Practice Address - Fax:860-678-7178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT50BEACON8CT01OtherANTHEM BC & BS
CTC02575Medicare ID - Type Unspecified