Provider Demographics
NPI:1396724811
Name:PROVIDERCARE PLUS PC
Entity type:Organization
Organization Name:PROVIDERCARE PLUS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR & CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:S
Authorized Official - Last Name:CARDAMONE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:860-644-4472
Mailing Address - Street 1:152 DEMING ST
Mailing Address - Street 2:PROVIDERCARE PLUS
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-3740
Mailing Address - Country:US
Mailing Address - Phone:860-644-4472
Mailing Address - Fax:860-644-3001
Practice Address - Street 1:152 DEMING ST
Practice Address - Street 2:PROVIDERCARE PLUS
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3740
Practice Address - Country:US
Practice Address - Phone:860-644-4472
Practice Address - Fax:860-644-3001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004398055Medicaid
CT004398055Medicaid