Basic Information
Provider Information | |||||||||
NPI: | 1487943114 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HEWARD | ||||||||
FirstName: | BRADY | ||||||||
MiddleName: | JOHN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 LONG WHARF DR STE 321 | ||||||||
Address2: |   | ||||||||
City: | NEW HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065115946 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037814600 | ||||||||
FaxNumber: | 2037814624 | ||||||||
Practice Location | |||||||||
Address1: | 1 LONG WHARF DR STE 321 | ||||||||
Address2: |   | ||||||||
City: | NEW HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065115946 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037814600 | ||||||||
FaxNumber: | 2037814624 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2011 | ||||||||
LastUpdateDate: | 08/28/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 300674 | NY | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 042.0013104 | VT | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 052173 | CT | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 004082260 | 05 | CT |   | MEDICAID | 008001325 | 05 | CT |   | MEDICAID | 008055441 | 05 | CT |   | MEDICAID | 004217099 | 05 | CT |   | MEDICAID | 008022622 | 05 | CT |   | MEDICAID | 1027719 | 05 | VT |   | MEDICAID |