Basic Information
| Provider Information | |||||||||
| NPI: | 1710375761 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIARA | ||||||||
| FirstName: | ERIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 N MAIN ST | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060422086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605333434 | ||||||||
| FaxNumber: | 8606476829 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 HAYNES ST | ||||||||
| Address2: | SUITE 1412 | ||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060404131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606476832 | ||||||||
| FaxNumber: | 8606476831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2014 | ||||||||
| LastUpdateDate: | 12/29/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1115 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 004025177 | 05 | CT | MEDICAID |