Provider Demographics
NPI:1962760561
Name:WELLMORE, INC
Entity type:Organization
Organization Name:WELLMORE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:STECK
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:203-574-9000
Mailing Address - Street 1:141 E MAIN ST
Mailing Address - Street 2:4TH FLOOR ADMINISTRATION
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-2310
Mailing Address - Country:US
Mailing Address - Phone:203-574-9000
Mailing Address - Fax:203-574-9006
Practice Address - Street 1:402 EAST MAIN ST
Practice Address - Street 2:WATERBURY OUTPATIENT BEHAVIORAL HEALTH SERVICES
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1701
Practice Address - Country:US
Practice Address - Phone:203-755-1143
Practice Address - Fax:203-753-3274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTDPH 0436/0528261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTGRP/FACILITYOtherUBH/OXFORD-FREEDOM HEALTH
CT008040528Medicaid
CTGRP/FACILITYOtherANTHEM BCBS OF CT
CTGRP/FACILITYOtherUBH-CONNECTICARE
CTD339210OtherBEACON HEALTH STRATEGIES
CTGRP/FACILITYOtherUBH-UNITED HEALTHCARE
CTGRP/FACILITYOtherMHN/MHN TRICARE NORTH
CTGRP/FACILITYOtherUNITED BEHAVIORAL HEALTH
CTGRP/FACILITYOtherOPTUM BEHAVIORAL HEALTH/UBH
CT0528OtherDPH-PSYCHIATRIC OUTPATIENT CLINIC FOR ADULTS
CT7882859OtherAETNA HEALTH PLAN
CTGRP/FACILITYOtherHEALTHYCT
CTLICENSE NO. 0436OtherDPH-FACILITY FOR THE CARE OR TREATMENT OF SUBSTANCE ABUSE OR DEPENDENT PERSONS
CT2266871OtherCIGNA BEHAVIORAL HEALTH
CTD339210OtherBEACON HEALTH STRATEGIES