Basic Information
Provider Information | |||||||||
NPI: | 1295336329 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY MATTERS OUTPATIENT PSYCHIATRIC CLINIC FOR CHILDREN, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 122 HARBISON AVE | ||||||||
Address2: |   | ||||||||
City: | HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061063013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8602828882 | ||||||||
FaxNumber: | 8602828890 | ||||||||
Practice Location | |||||||||
Address1: | 531 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | EAST HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061083305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8602828882 | ||||||||
FaxNumber: | 8602828890 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/04/2020 | ||||||||
LastUpdateDate: | 11/04/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCDOUGALD | ||||||||
AuthorizedOfficialFirstName: | TANGIE | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | LICENSED PROFESSIONAL COUNSELOR | ||||||||
AuthorizedOfficialTelephone: | 8602828882 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LPC | ||||||||
NPICertificationDate: | 11/04/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 261QC1500X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QM0801X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0855X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.