Basic Information
| Provider Information | |||||||||
| NPI: | 1245430891 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERCOMMUNITY MENTAL HEALTH GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 281 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061181823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605695900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 505 SILAS DEANE HWY | ||||||||
| Address2: | |||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061092216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605695900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2007 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | GAINES | ||||||||
| AuthorizedOfficialFirstName: | MARSHALL | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 8608952308 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MBA, CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | C-0109 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 312837 | 01 | CT | MHN | OTHER |