Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 101YA0400X | Counselor | Addiction (Substance Use Disorder) | 001104 | CONNECTICUT | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 060669107 | OTHER | CONNECTICUT | HEALTHYCT WELLMORE GRP/FACILITY |
| 2 | PENDING | OTHER | CONNECTICUT | CAQH |
| 3 | PENDING | OTHER | CONNECTICUT | MHN MANAGED HEALTH NETWORK |
| 4 | 060669107 | OTHER | CONNECTICUT | UNITED BEHAVIORAL HEALTH- OPTUM WELLMORE GRP/FACILITY |
| 5 | 060669107 | OTHER | CONNECTICUT | UBH- CONNECTICARE WELLMORE GRP/FACILITY |
| 6 | ICADC-5511 | OTHER | CONNECTICUT | ICADC INTERNATIONALLY CERTIFIED ADDICTION COUNSELOR CCB |
| 7 | 060669107 | OTHER | CONNECTICUT | UBH-UNITED HEALTHCARE WELLMORE GRP/FACILITY |
| 8 | PENDING | OTHER | CONNECTICUT | AETNA BEHAVIORAL HEALTH |
| 9 | 060669107 | OTHER | CONNECTICUT | UBH-OXFORD HEALTH LIBERTY/FREEDOM WELLMORE GRP/FACILITY |
| 10 | NOT ELIGIBLE | MEDICARE UPIN | CONNECTICUT | |
| 11 | CAC-5511 | OTHER | CONNECTICUT | CAC- CERTIFIED ADDICTION COUNSELOR CCB |
| 12 | PENDING | OTHER | CONNECTICUT | MHN TRICARE NORTH |
| 13 | APP-5511 | OTHER | CONNECTICUT | APP ASSOCIATE PREVENTION PROFESSIONAL CCB |
| 14 | PENDING | OTHER | CONNECTICUT | CIGNA BEHAVIORAL HEALTH |
| 15 | PENDING | MEDICAID | CONNECTICUT | |
| 16 | 060669107 | OTHER | CONNECTICUT | ANTHEM BCBS OF CT WELLMORE GRP/FACILITY |
