Healthcare Provider Details

I. General information

NPI: 1801050398
Provider Name (Legal Business Name): ANDOVER, HEBRON, MARLBOROUGH YOUTH & FAMILY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 PENDLETON DR
HEBRON CT
06248-1525
US

IV. Provider business mailing address

25 PENDLETON DR
HEBRON CT
06248-1525
US

V. Phone/Fax

Practice location:
  • Phone: 860-228-9488
  • Fax: 860-228-1213
Mailing address:
  • Phone: 860-228-9488
  • Fax: 860-228-1213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. SARAH KATE EKVALL
Title or Position: CLINICAL DEPARTMENT
Credential:
Phone: 860-228-9488