Healthcare Provider Details

I. General information

NPI: 1811653447
Provider Name (Legal Business Name): GREAT AMBITIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 GLEN HILL RD
WILTON CT
06897-2424
US

IV. Provider business mailing address

95 GLEN HILL RD
WILTON CT
06897-2424
US

V. Phone/Fax

Practice location:
  • Phone: 917-804-3106
  • Fax:
Mailing address:
  • Phone: 917-804-3106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: TOM ZEF DUSI
Title or Position: EMPLOYEE
Credential: BCBA
Phone: 917-804-3106