Healthcare Provider Details

I. General information

NPI: 1528241189
Provider Name (Legal Business Name): LIBERATION PROGRAMS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 MAIN ST
STAMFORD CT
06901-2818
US

IV. Provider business mailing address

4 ELMCREST TER
NORWALK CT
06850-3908
US

V. Phone/Fax

Practice location:
  • Phone: 203-356-1980
  • Fax: 203-353-0368
Mailing address:
  • Phone: 203-851-2077
  • Fax: 203-851-2082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberSA0174
License Number StateCT

VIII. Authorized Official

Name: MR. ALAN MATHIS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 203-851-2077