Healthcare Provider Details

I. General information

NPI: 1598279689
Provider Name (Legal Business Name): CONNECTICUT COUNSELING CENTERS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 11/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 BROOKSIDE RD
WATERBURY CT
06708-1402
US

IV. Provider business mailing address

50 BROOKSIDE RD
WATERBURY CT
06708-1402
US

V. Phone/Fax

Practice location:
  • Phone: 203-568-7466
  • Fax: 203-568-7468
Mailing address:
  • Phone: 203-568-7466
  • Fax: 203-568-7468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number0067
License Number StateCT

VIII. Authorized Official

Name: JASON BRADWAY
Title or Position: DIRECTOR INFORMATION SYSTEMS
Credential:
Phone: 203-568-7466