Healthcare Provider Details

I. General information

NPI: 1811426695
Provider Name (Legal Business Name): FAIRFIELD COUNTY HEALTH & WELLNESS SERVICES II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 06/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 REEF ROAD/SUITE 109
FAIRFIELD CT
06824
US

IV. Provider business mailing address

21 MAPLE RIDGE RD
TRUMBULL CT
06611-5522
US

V. Phone/Fax

Practice location:
  • Phone: 203-955-1821
  • Fax: 203-955-1823
Mailing address:
  • Phone: 203-671-3587
  • Fax: 203-671-3587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number033954
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number033954
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number033954
License Number StateCT

VIII. Authorized Official

Name: PROF. CARINE JEAN
Title or Position: OWNER/MD
Credential: MD
Phone: 203-671-3587