Healthcare Provider Details

I. General information

NPI: 1033239249
Provider Name (Legal Business Name): SOUTHERN CT CHRISTIAN NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 DURHAM RD MAILBOX 7
MADISON CT
06443-2674
US

IV. Provider business mailing address

145 DURHAM RD MAILBOX 7
MADISON CT
06443-2674
US

V. Phone/Fax

Practice location:
  • Phone: 203-318-0070
  • Fax: 206-339-8205
Mailing address:
  • Phone: 203-318-0070
  • Fax: 206-339-8205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number001460
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002876
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number004809
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number039301
License Number StateCT

VIII. Authorized Official

Name: MRS. ULARI DIKE
Title or Position: OFFICE MANAGER
Credential:
Phone: 203-318-0700