Basic Information
| Provider Information | |||||||||
| NPI: | 1225297690 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VISTA BEHAVIORAL HEALTH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 152 SIMSBURY RD | ||||||||
| Address2: | BUILDING 9 2ND FLOOR | ||||||||
| City: | AVON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060013777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602693101 | ||||||||
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| Practice Location | |||||||||
| Address1: | 152 SIMSBURY RD | ||||||||
| Address2: | BUILDING 9 2ND FLOOR | ||||||||
| City: | AVON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060013777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602693101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2008 | ||||||||
| LastUpdateDate: | 09/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | MENDES | ||||||||
| AuthorizedOfficialFirstName: | ASANTE | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8602693101 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 046042 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.