Provider Demographics
NPI:1730442179
Name:WBC CONNECTICUT EAST, LLC
Entity type:Organization
Organization Name:WBC CONNECTICUT EAST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:
Authorized Official - Last Name:KOMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:781-647-6701
Mailing Address - Street 1:880 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-8500
Mailing Address - Country:US
Mailing Address - Phone:781-647-6767
Mailing Address - Fax:781-647-6755
Practice Address - Street 1:2400 TAMARACK AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-5555
Practice Address - Country:US
Practice Address - Phone:860-533-4672
Practice Address - Fax:860-533-4673
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALDEN BEHAVIORAL CARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-20
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT=========OtherTAX ID