Healthcare Provider Details

I. General information

NPI: 1255601548
Provider Name (Legal Business Name): AFFILIATES FOR CONSULTATION AND PSYCHOTHERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2012
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

389 ORANGE ST.
NEW HAVEN CT
06511-6406
US

IV. Provider business mailing address

389 ORANGE ST.
NEW HAVEN CT
06511-6406
US

V. Phone/Fax

Practice location:
  • Phone: 203-562-4235
  • Fax: 203-624-6600
Mailing address:
  • Phone: 203-562-4235
  • Fax: 203-624-6600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateCT
# 6
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateCT
# 7
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCT
# 8
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateCT

VIII. Authorized Official

Name: MR. THOMAS G. CAMPBELL
Title or Position: GENERAL PARTNER AND PRACTICE DIRECT
Credential: L.C.S.W.
Phone: 203-562-4235