Healthcare Provider Details

I. General information

NPI: 1982201927
Provider Name (Legal Business Name): FUN 2B FREE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2020
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 VICTORIA DR
CHESHIRE CT
06410-7126
US

IV. Provider business mailing address

150 VICTORIA DR
CHESHIRE CT
06410-7126
US

V. Phone/Fax

Practice location:
  • Phone: 203-819-2025
  • Fax:
Mailing address:
  • Phone: 203-819-2025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: TAMMY JACKSON
Title or Position: OWNER
Credential: MBA, BCBA, LBA
Phone: 203-819-2025