1275717019 NPI number — CENTER FOR FAMILY & INDIVIDUAL PSYCHOTHERAPY, LLC

Table of content: (NPI 1275717019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275717019 NPI number — CENTER FOR FAMILY & INDIVIDUAL PSYCHOTHERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR FAMILY & INDIVIDUAL PSYCHOTHERAPY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275717019
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
76 SOUTH FRONTAGE ROAD
Provider Second Line Business Mailing Address:
P.O. BOX 2333
Provider Business Mailing Address City Name:
VERNON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06066-2250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-872-4570
Provider Business Mailing Address Fax Number:
860-896-1023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
76 S FRONTAGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VERNON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06066-5535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-872-4570
Provider Business Practice Location Address Fax Number:
860-896-1023
Provider Enumeration Date:
12/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HORTON
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
860-872-4570

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  703 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 06000703CT02 . This is a "BCBS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 62484313 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 133603 . This is a "VALUE OPTIONS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: A379004 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 62741 . This is a "CIGNA BEHAVIORAL HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 4534633 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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