Healthcare Provider Details

I. General information

NPI: 1750378667
Provider Name (Legal Business Name): LIFEBRIDGE COMMUNITY SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 PENFIELD ROAD
FAIRFIELD CT
06824-6639
US

IV. Provider business mailing address

125 PENFIELD RD.
FAIRFIELD CT
06824-6639
US

V. Phone/Fax

Practice location:
  • Phone: 203-255-5777
  • Fax: 203-259-9673
Mailing address:
  • Phone: 203-255-5777
  • Fax: 203-259-9673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number0400
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0334
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0400
License Number StateCT

VIII. Authorized Official

Name: FRANK FARIAS
Title or Position: CHIEF FINANCIAL & HR OFFICER
Credential:
Phone: 203-368-4291