Provider Demographics
NPI:1265626899
Name:MIND MANAGEMENT SERVICES INC
Entity type:Organization
Organization Name:MIND MANAGEMENT SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER / VICE PRESI
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PAGE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-889-4944
Mailing Address - Street 1:20 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-4753
Mailing Address - Country:US
Mailing Address - Phone:860-889-4944
Mailing Address - Fax:860-889-4944
Practice Address - Street 1:20 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-4753
Practice Address - Country:US
Practice Address - Phone:860-889-4944
Practice Address - Fax:860-889-4944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1041C0700X251S00000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004254976Medicaid
CT140003950CT01OtherANTHEM BC/BS
CT=========OtherTRICARE
CTCO2330Medicare UPIN