NPIMap

Organization Active NPI

Masonicare Behavioral Health, LLC

  • Geriatric Psychiatry Physician
  • Wallingford, CT
National Provider Identifier
1992781488
Registry record updated Jun 6, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Geriatric Psychiatry PhysicianTaxonomy code 2084P0805X
Legal business name
MASONICARE BEHAVIORAL HEALTH, LLC
Practice address
67 Masonic Ave
1St Floor
Wallingford, CT 06492-3095
Phone
(203) 265-5720
Fax
(203) 679-5623
NPI assigned
Dec 16, 2005
Last updated
Jun 6, 2014By the provider in NPPES
Organization subpart
Yes
Parent organization
MASONICARE PRIMARY CARE PHYSICIANS, PCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 6, 2014

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

Authorized official

Name
John Tibbetts
Title
Authorized Official
Phone
(203) 265-5720

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Geriatric Psychiatry Physician 2084P0805X Primary

Addresses

Primary practice location

67 Masonic Ave
1St Floor
Wallingford, CT 06492-3095

Mailing address

67 Masonic Ave
1St Floor
Wallingford, CT 06492-3095
Phone (203) 265-5720

Other identifiers 1

IdentifierTypeStateIssuer
004183050MedicaidCT

National Provider Directory

National Provider Directory
Part of
Masonicare Primary Care Physicians

Locations

67 Masonic Ave
Fl 1
Wallingford, CT 06492
Phone (203) 265-0355

97 Barnes Rd
Ste 2
Wallingford, CT 06492
Phone (203) 265-5720

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 181

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.

View all 181

NPI Registry JSON

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

{
    "created_epoch": "1134691200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1402012800000",
    "number": "1992781488",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "67 MASONIC AVE",
            "address_2": "1ST FLOOR",
            "city": "WALLINGFORD",
            "state": "CT",
            "postal_code": "064923095",
            "telephone_number": "203-265-5720",
            "fax_number": "203-679-5623"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "67 MASONIC AVE",
            "address_2": "1ST FLOOR",
            "city": "WALLINGFORD",
            "state": "CT",
            "postal_code": "064923095",
            "telephone_number": "203-265-5720",
            "fax_number": "203-679-5623"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MASONICARE BEHAVIORAL HEALTH, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MASONICARE PRIMARY CARE PHYSICIANS, PC",
        "enumeration_date": "2005-12-16",
        "last_updated": "2014-06-06",
        "status": "A",
        "authorized_official_last_name": "TIBBETTS",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "AUTHORIZED OFFICIAL",
        "authorized_official_telephone_number": "203-265-5720"
    },
    "taxonomies": [
        {
            "code": "2084P0805X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Geriatric Psychiatry",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "004183050",
            "state": "CT"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Wallingford, CT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 6, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.