Healthcare Provider Details

I. General information

NPI: 1669731360
Provider Name (Legal Business Name): FARMINGTON RIVER MENTAL HEALTH SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 09/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 W AVON RD STE 204
AVON CT
06001-3679
US

IV. Provider business mailing address

46 W AVON RD STE 204
AVON CT
06001-3679
US

V. Phone/Fax

Practice location:
  • Phone: 860-307-8943
  • Fax: 860-824-1469
Mailing address:
  • Phone: 860-307-8943
  • Fax: 860-824-1469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number005693
License Number StateCT

VIII. Authorized Official

Name: MRS. DEBRA M CARROLL
Title or Position: DIRECTOR
Credential: LCSW
Phone: 860-307-8943