Basic Information
| Provider Information | |||||||||
| NPI: | 1073548533 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERCOMMUNITY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 281 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061181883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605695900 | ||||||||
| FaxNumber: | 8605695614 | ||||||||
| Practice Location | |||||||||
| Address1: | 281 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061181883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605695900 | ||||||||
| FaxNumber: | 8605695614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | BEAUREGARD | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO & PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8605695900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | C0178 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QP2300X | 702 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 004050993 | 05 | CT | MEDICAID | 312837 | 01 | MHN | OTHER | 008047966 | 05 | CT | MEDICAID |