Provider Demographics
NPI:1134251564
Name:SHORELINE PSYCHIATRY OF WESTERN CONNECTICUT, LLC
Entity type:Organization
Organization Name:SHORELINE PSYCHIATRY OF WESTERN CONNECTICUT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:STUKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-656-1452
Mailing Address - Street 1:71 EAST AVE
Mailing Address - Street 2:SUITE V
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-4903
Mailing Address - Country:US
Mailing Address - Phone:203-656-1452
Mailing Address - Fax:203-656-1485
Practice Address - Street 1:71 EAST AVE
Practice Address - Street 2:SUITE V
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-4903
Practice Address - Country:US
Practice Address - Phone:203-656-1452
Practice Address - Fax:203-656-1485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT=========OtherTAX ID NUMBER
CTDF9868Medicare PIN
CT=========OtherTAX ID NUMBER