NPIMap

Organization Active NPI

Staywell Health Care Inc

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Waterbury, CT
National Provider Identifier
1083022230
Registry record updated Feb 12, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X
License
0479 Issued in CT
Legal business name
STAYWELL HEALTH CARE INC
Practice address
402 E Main St
Waterbury, CT 06702-1701
Phone
(203) 755-1143
Fax
(203) 753-3274
NPI assigned
Jul 31, 2014
Last updated
Feb 12, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 12, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Don Thompson
Title
Ceo
Phone
(203) 756-8021

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 0479 CT
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X 0479 CT Primary
Addiction Medicine (Family Medicine) Physician 207QA0401X 0479 CT

Addresses

Primary practice location

402 E Main St
Waterbury, CT 06702-1701

Mailing address

80 Phoenix Ave
Suite 201
Waterbury, CT 06702-1418
Phone (203) 756-8021

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CT

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20140829002189 CT Part A Provider - Federally Qualified Health Center (FQHC) 6305750480 1 other NPI on this enrollment
Practice locations: Waterbury, CT

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1083022230. Details of each certification follow.

Federally qualified health center certification: CCN 071908

Legal name
STAYWELL HEALTH CARE INC.
Doing business as
STAYWELL HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 17, 2014
Last certification
Nov 17, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Dec 11, 1994 in CT
Enrollment address
402 E Main St
Waterbury, CT 67021701

Other NPIs with the same Medicare PAC ID 6

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Staywell Health Care Inc6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

Organizations that report the same tax identification number in the National Provider Directory.

Locations

30 Church St
Naugatuck, CT 06770
Phone (203) 805-4929

1309 S Main St
Waterbury, CT 06706
Phone (203) 597-9044

Ownership & related parties

All disclosed owners & managing parties 18

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Christopher M King Individual Corporate OfficerBoard Member Jan 8, 2007
Sunil B Dcunha Individual Corporate DirectorCmo Jul 1, 2004
Amit Patel Individual Corporate DirectorDental Director Sep 1, 2001
Thomas Johnson Individual Corporate OfficerBoard Member Oct 15, 2012
Carolyn a Highsmith Individual Corporate OfficerBoard Member Feb 1, 2010
Sandra J Sorel-Leduc Individual Corporate OfficerBoard Member Mar 1, 2004
Migdalia Rosario Individual Corporate OfficerChairperson Jan 1, 1999
Beverly a Lyons Individual Corporate DirectorDirector of Behavioral Health Sep 26, 2006
Lule G Tracey Individual Corporate DirectorCfo Feb 1, 1999
Christine S Bianchi Individual Corporate DirectorChief Development Officer Jul 1, 2011
Donald J Thompson Individual Corporate Officer Sep 11, 1989
Mark L Briggs Individual Corporate OfficerVice Chair Board of Directors Feb 6, 2006
June Lewis Individual W-2 Managing EmployeeOffice Manager Sep 29, 1980
Abby Dibattista Individual W-2 Managing EmployeeBilling Manager Jan 1, 2014
Arlene M Arias Individual Corporate Officer Nov 7, 2005
Naga S Yalamachili Individual Corporate DirectorInformation Systems Director Jul 1, 2006
Judy a Acosta Individual Corporate OfficerBoard Member Consumer Aug 13, 2012
Karen Moody Individual W-2 Managing EmployeeOffice Manager Jun 30, 2006

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1406764800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1518393600000",
    "number": "1083022230",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "80 PHOENIX AVE",
            "address_2": "SUITE 201",
            "city": "WATERBURY",
            "state": "CT",
            "postal_code": "067021418",
            "telephone_number": "203-756-8021",
            "fax_number": "203-596-9038"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "402 E MAIN ST",
            "city": "WATERBURY",
            "state": "CT",
            "postal_code": "067021701",
            "telephone_number": "203-755-1143",
            "fax_number": "203-753-3274"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STAYWELL HEALTH CARE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-07-31",
        "last_updated": "2018-02-12",
        "status": "A",
        "authorized_official_last_name": "THOMPSON",
        "authorized_official_first_name": "DON",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "203-756-8021"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "CT",
            "license": "0479",
            "primary": false
        },
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": "CT",
            "license": "0479",
            "primary": true
        },
        {
            "code": "207QA0401X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Addiction Medicine",
            "state": "CT",
            "license": "0479",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Waterbury, CT

Sources for this page

Verify at the official NPI Registry.