Basic Information
| Provider Information | |||||||||
| NPI: | 1477999340 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STAYWELL HEALTH CARE INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 PHOENIX AVE | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067021418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037568021 | ||||||||
| FaxNumber: | 2035969038 | ||||||||
| Practice Location | |||||||||
| Address1: | 1309 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067061758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035979044 | ||||||||
| FaxNumber: | 2035969038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2013 | ||||||||
| LastUpdateDate: | 02/08/2018 | ||||||||
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| AuthorizedOfficialLastName: | ESTRADA | ||||||||
| AuthorizedOfficialFirstName: | ALEXIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2037568021 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 0506 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 261QF0400X | 0474 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QM0801X | 0479 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 004235968 | 05 | CT | MEDICAID |