Healthcare Provider Details

I. General information

NPI: 1215393327
Provider Name (Legal Business Name): CHILD AND FAMILY AGENCY OF SOUTHEASTERN CONNECTICUT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 VAUXHALL ST
NEW LONDON CT
06320-5711
US

IV. Provider business mailing address

255 HEMPSTEAD ST
NEW LONDON CT
06320-6204
US

V. Phone/Fax

Practice location:
  • Phone: 860-442-2797
  • Fax: 860-701-3776
Mailing address:
  • Phone: 860-443-2896
  • Fax: 860-442-5909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number0586
License Number StateCT

VIII. Authorized Official

Name: LISA BAXTER
Title or Position: CHIEF FINANCIAL AND ADMIN OFFICER
Credential:
Phone: 860-443-2896