Provider Demographics
NPI:1942274618
Name:INTRASPECTUS, LLC
Entity Type:Organization
Organization Name:INTRASPECTUS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:KEREKES
Authorized Official - Suffix:
Authorized Official - Credentials:MSSW, LCSW
Authorized Official - Phone:203-676-0880
Mailing Address - Street 1:93 LYON ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-4925
Mailing Address - Country:US
Mailing Address - Phone:203-676-0880
Mailing Address - Fax:
Practice Address - Street 1:93 LYON ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4925
Practice Address - Country:US
Practice Address - Phone:203-676-0880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005553261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT333779OtherMHN
CT140005553CT01OtherBCBS