Basic Information
| Provider Information | |||||||||
| NPI: | 1699723007 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VERICARE, P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | VERICARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 55 HATCHETTS HILL RD | ||||||||
| Address2: | |||||||||
| City: | OLD LYME | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063711534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003703651 | ||||||||
| FaxNumber: | 8775157147 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 WHITLEY RD | ||||||||
| Address2: | |||||||||
| City: | KELLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762483038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002578715 | ||||||||
| FaxNumber: | 8008191655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 07/10/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 04/11/2007 | ||||||||
| NPIReactivationDate: | 08/08/2007 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, CREDENTIALING ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 8003703651 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 103TC0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 136136214 | 05 | TX | MEDICAID | CB3582 | 01 | TX | RAILROAD MEDICARE | OTHER |