Healthcare Provider Details

I. General information

NPI: 1477583581
Provider Name (Legal Business Name): BOYS & GIRLS VILLAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 WHEELERS FARMS RD
MILFORD CT
06461-1847
US

IV. Provider business mailing address

528 WHEELERS FARMS RD
MILFORD CT
06461-1847
US

V. Phone/Fax

Practice location:
  • Phone: 203-877-0300
  • Fax: 203-876-0076
Mailing address:
  • Phone: 203-877-0300
  • Fax: 203-876-0076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberEDT-10
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberOPCC-38
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberCCF/TS 17
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberCPA-40
License Number StateCT

VIII. Authorized Official

Name: MR. L. KENNETH FELLENBAUM
Title or Position: CEO
Credential:
Phone: 203-877-0300