Basic Information
| Provider Information | |||||||||
| NPI: | 1578819884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALI | ||||||||
| FirstName: | TABASSUM | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 4TH FLOOR ADMINISTATION | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | WATERBURY CLINICIAL SERVICES 2ND FLOOR | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8559355667 | ||||||||
| FaxNumber: | 2035960722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2012 | ||||||||
| LastUpdateDate: | 05/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 98808 | CT | N | Nursing Service Providers | Registered Nurse | 163WP0807X | ANCC2012007952 | CT | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Child & Adolescent | 363LP0808X | 005035 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 060669107 | 01 | CT | UBH-UNITED BEHAVIORAL HEALTH NETWORK WELLMORE GRP/FACILITY | OTHER | 12671467 | 01 | CAQH | OTHER | 507335 | 01 | CT | MHN/MANAGED HEALTH NETWORK | OTHER | CSP.0053391 | 01 | CT | CONTROLLED SUBSTANCE LICENSE | OTHER | 4853955 | 01 | CT | CIGNA BEHAVIORAL HEALTH | OTHER | 9777891 | 01 | CT | AETNA BEHAVIORAL HEALTH | OTHER | MA2685127 | 01 | DEA LICENSE | OTHER | 060669107 | 01 | CT | HCT-HEALTHY CT WELLMORE GRP/FACILITY CONTRACT | OTHER | 060669107 | 01 | CT | UBH-UNITED HEALTHCARE WELLMORE GRP/FACILITY | OTHER | 507335 | 01 | CT | TRICARE NORTH | OTHER | 060669107 | 01 | CT | ANTHEM BCBS OF CT BEHAVIORAL HEALTH-WELLMORE GRP/FACILITY | OTHER | 008042033 | 05 | CT | MEDICAID | D339209 WATERBURY | 01 | CT | VALUE OPTIONS/BEACON HEALTH STRATEGIES | OTHER | 060669107 | 01 | CT | UBH-OXFORD HEALTH/LIBERTY GRP/FACILITY | OTHER | CSP.0053391 | 01 | CT | CONTROLLED SUBSTANCE REGISTRATION FOR PRACTITIONER | OTHER |