Healthcare Provider Details

I. General information

NPI: 1063437895
Provider Name (Legal Business Name): TOWN OF BRANFORD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 02/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

342 HARBOR STREET
BRANFORD CT
06405
US

IV. Provider business mailing address

342 HARBOR STREET
BRANFORD CT
06405
US

V. Phone/Fax

Practice location:
  • Phone: 203-481-4248
  • Fax: 203-483-7727
Mailing address:
  • Phone: 203-481-4248
  • Fax: 203-483-7727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number002668
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number005435
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1942449186
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number014248
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberC01490
License Number StateCT
# 6
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberC0149
License Number StateCT

VIII. Authorized Official

Name: PETER CIMINO
Title or Position: EXECUTIVE DIRECTOR
Credential: LPC
Phone: 203-481-4248