Healthcare Provider Details

I. General information

NPI: 1083921506
Provider Name (Legal Business Name): FAMILY AFFIRMATION CENTER FOR TREATMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2010
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 HARTFORD TPKE SUITE 201
VERNON CT
06066-4784
US

IV. Provider business mailing address

281 HARTFORD TPKE SUITE 201
VERNON CT
06066-4784
US

V. Phone/Fax

Practice location:
  • Phone: 860-896-5331
  • Fax: 860-896-5334
Mailing address:
  • Phone: 860-896-5331
  • Fax: 860-896-5334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number004829
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number006240
License Number StateCT

VIII. Authorized Official

Name: JESSICA KELTON
Title or Position: PARTNER
Credential: LCSW
Phone: 860-896-5331