Healthcare Provider Details

I. General information

NPI: 1124689922
Provider Name (Legal Business Name): CONSTELLATION SCHOOL BASED THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 WESTPORT AVE
NORWALK CT
06851-3915
US

IV. Provider business mailing address

14 WESTPORT AVE
NORWALK CT
06851-3915
US

V. Phone/Fax

Practice location:
  • Phone: 203-663-6771
  • Fax:
Mailing address:
  • Phone: 203-663-6771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: JASON ALAN CREUTZMANN
Title or Position: ADMINISTRATOR
Credential:
Phone: 203-663-6771