Provider Demographics
NPI:1538428206
Name:MENTAGEN ADVANCED BEHAVIORAL MEDICINE, PC
Entity type:Organization
Organization Name:MENTAGEN ADVANCED BEHAVIORAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAMSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-338-4864
Mailing Address - Street 1:74 NEW LONDON TPKE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4204
Mailing Address - Country:US
Mailing Address - Phone:860-338-4864
Mailing Address - Fax:
Practice Address - Street 1:74 NEW LONDON TPKE
Practice Address - Street 2:SUITE 5
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4204
Practice Address - Country:US
Practice Address - Phone:860-338-4864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty