1467097667 NPI number — CHILD AND FAMILY AGENCY OF SOUTHEASTERN CONNECTICUT, INC.

Table of content: (NPI 1467097667)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467097667 NPI number — CHILD AND FAMILY AGENCY OF SOUTHEASTERN CONNECTICUT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILD AND FAMILY AGENCY OF SOUTHEASTERN CONNECTICUT, INC.
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:
1467097667
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
255 HEMPSTEAD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW LONDON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06320-6204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-443-2896
Provider Business Mailing Address Fax Number:
860-442-5909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 MISTUXET AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYSTIC
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06355-3009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-536-8613
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/12/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BAXTER
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFAO
Authorized Official Telephone Number:
860-443-2896

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1065 . This is a "SCHOOL BASED HEALTH CENTER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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