Basic Information
| Provider Information | |||||||||
| NPI: | 1730694316 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IMPACT HEALTH P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 WESTPORT AVE | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068513915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0000000000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14 WESTPORT AVE | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0000000000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2017 | ||||||||
| LastUpdateDate: | 07/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | DESILVA | ||||||||
| AuthorizedOfficialFirstName: | GARUMUNI | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED PERSON | ||||||||
| AuthorizedOfficialTelephone: | 2039880766 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TB0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC1900X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 251J00000X | N | Agencies | Nursing Care | 363LA2200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LG0600X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363L00000X | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.