Provider Demographics
NPI:1174886188
Name:CT CENTER FOR BLADDER HEALTH LLC
Entity type:Organization
Organization Name:CT CENTER FOR BLADDER HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:860-670-3039
Mailing Address - Street 1:20 N MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-2524
Mailing Address - Country:US
Mailing Address - Phone:860-670-3039
Mailing Address - Fax:
Practice Address - Street 1:136 HAZARD AVE BLDG 6
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4520
Practice Address - Country:US
Practice Address - Phone:860-670-3039
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-25
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004196363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty