Provider Demographics
NPI:1992781488
Name:MASONICARE BEHAVIORAL HEALTH, LLC
Entity type:Organization
Organization Name:MASONICARE BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:TIBBETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-265-5720
Mailing Address - Street 1:67 MASONIC AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-3095
Mailing Address - Country:US
Mailing Address - Phone:203-265-5720
Mailing Address - Fax:203-679-5623
Practice Address - Street 1:67 MASONIC AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-3095
Practice Address - Country:US
Practice Address - Phone:203-265-5720
Practice Address - Fax:203-679-5623
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MASONICARE PRIMARY CARE PHYSICIANS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-16
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004183050Medicaid
CTC02770Medicare PIN