Healthcare Provider Details

I. General information

NPI: 1326587882
Provider Name (Legal Business Name): FULL CIRCLE FAMILY SERVICES AT WHITE BROOK FARM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2017
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 MAIN ST
DANIELSON CT
06239-2815
US

IV. Provider business mailing address

PO BOX 67
DANIELSON CT
06239-0067
US

V. Phone/Fax

Practice location:
  • Phone: 860-753-6015
  • Fax: 877-552-0608
Mailing address:
  • Phone: 860-753-6015
  • Fax: 877-552-0608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number009611
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: LISA MARIE RIVERA
Title or Position: OWNER
Credential: LCSW
Phone: 860-753-6015