Healthcare Provider Details

I. General information

NPI: 1932473527
Provider Name (Legal Business Name): A PROSPERING VISION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2012
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 N MAIN ST 3RD FLR
WATERBURY CT
06702-1443
US

IV. Provider business mailing address

60 N MAIN ST 3RD FLR
WATERBURY CT
06702-1443
US

V. Phone/Fax

Practice location:
  • Phone: 203-558-9865
  • Fax:
Mailing address:
  • Phone: 203-558-9865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084D0003X
TaxonomyDiagnostic Neuroimaging (Psychiatry & Neurology) Physician
License Number040650
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number54084595001
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5149
License Number StateCT

VIII. Authorized Official

Name: MR. ELIJAH CALDWELL
Title or Position: EXECUTIVE PROGRAM DIRECTOR
Credential: LCSW
Phone: 203-558-9865