Healthcare Provider Details

I. General information

NPI: 1235668096
Provider Name (Legal Business Name): OUR COMMUNITY COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 05/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 HAZEL TER STE J
WOODBRIDGE CT
06525-2240
US

IV. Provider business mailing address

PO BOX 3301
NEW HAVEN CT
06515-0401
US

V. Phone/Fax

Practice location:
  • Phone: 203-787-8812
  • Fax: 203-367-7721
Mailing address:
  • Phone: 203-787-8812
  • Fax: 203-387-7721

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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SHAMAR J YOUNG
Title or Position: OWNER
Credential: LMSW, LCSW
Phone: 203-787-8812