Healthcare Provider Details

I. General information

NPI: 1811431190
Provider Name (Legal Business Name): THE TREEHOUSE CENTER FOR CHILDREN AND FAMILIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 W STAFFORD RD SUITE 2
STAFFORD SPRINGS CT
06076-1000
US

IV. Provider business mailing address

72 W STAFFORD RD SUITE 2
STAFFORD SPRINGS CT
06076-1000
US

V. Phone/Fax

Practice location:
  • Phone: 860-684-5015
  • Fax: 860-684-3749
Mailing address:
  • Phone: 860-684-5015
  • Fax: 860-684-3749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number037680
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number005863
License Number StateCT

VIII. Authorized Official

Name: DR. TERRY M ECCLES
Title or Position: PARTNER
Credential: MD
Phone: 860-684-5015