Healthcare Provider Details

I. General information

NPI: 1962926576
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: 07/26/2017
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 WALLER ST
NEW LONDON CT
06320-5216
US

IV. Provider business mailing address

255 HEMPSTEAD ST
NEW LONDON CT
06320-6204
US

V. Phone/Fax

Practice location:
  • Phone: 860-437-6480
  • Fax: 860-701-3772
Mailing address:
  • Phone: 860-443-2896
  • Fax: 860-442-5909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number0138
License Number StateCT

VIII. Authorized Official

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