Basic Information
| Provider Information | |||||||||
| NPI: | 1962760561 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLMORE, INC | ||||||||
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| OtherOrganizationName: | WELLMORE, INC.-WATERBURY OP BEHAVIORAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 4TH FLOOR ADMINISTRATION | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 402 EAST MAIN ST | ||||||||
| Address2: | WATERBURY OUTPATIENT BEHAVIORAL HEALTH SERVICES | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067021701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037551143 | ||||||||
| FaxNumber: | 2037533274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2012 | ||||||||
| LastUpdateDate: | 08/23/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STECK | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2035749000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LMFT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | DPH 0436/0528 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | GRP/FACILITY | 01 | CT | UBH/OXFORD-FREEDOM HEALTH | OTHER | 008040528 | 05 | CT | MEDICAID | GRP/FACILITY | 01 | CT | ANTHEM BCBS OF CT | OTHER | GRP/FACILITY | 01 | CT | UBH-CONNECTICARE | OTHER | D339210 | 01 | CT | BEACON HEALTH STRATEGIES | OTHER | GRP/FACILITY | 01 | CT | UBH-UNITED HEALTHCARE | OTHER | GRP/FACILITY | 01 | CT | MHN/MHN TRICARE NORTH | OTHER | GRP/FACILITY | 01 | CT | UNITED BEHAVIORAL HEALTH | OTHER | GRP/FACILITY | 01 | CT | OPTUM BEHAVIORAL HEALTH/UBH | OTHER | 0528 | 01 | CT | DPH-PSYCHIATRIC OUTPATIENT CLINIC FOR ADULTS | OTHER | 7882859 | 01 | CT | AETNA HEALTH PLAN | OTHER | GRP/FACILITY | 01 | CT | HEALTHYCT | OTHER | LICENSE NO. 0436 | 01 | CT | DPH-FACILITY FOR THE CARE OR TREATMENT OF SUBSTANCE ABUSE OR DEPENDENT PERSONS | OTHER | 2266871 | 01 | CT | CIGNA BEHAVIORAL HEALTH | OTHER |