Basic Information
| Provider Information | |||||||||
| NPI: | 1588604060 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDOPTIONS BEHAVIORAL HEALTH ASSOC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 RESEARCH PKWY | ||||||||
| Address2: | SUITE C | ||||||||
| City: | OLD SAYBROOK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064754214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003703651 | ||||||||
| FaxNumber: | 8605100020 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 RESEARCH PKWY | ||||||||
| Address2: | SUITE C | ||||||||
| City: | OLD SAYBROOK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064754214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003703651 | ||||||||
| FaxNumber: | 8605100020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 05/26/2009 | ||||||||
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| AuthorizedOfficialLastName: | DE GRAY | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MNGR | ||||||||
| AuthorizedOfficialTelephone: | 8003703651 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 103TC0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 363L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.