=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063956852
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPASS BEHAVIORAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2016
-----------------------------------------------------
Last Update Date | 12/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 43 SHERMAN HILL RD BUILDING D, SUITE 104
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06798-3651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-516-8852
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 88 RIDGEVIEW AVE
-----------------------------------------------------
City | TRUMBULL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06611-1937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-516-8852
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KEITH O'DONNELL
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 203-516-8852
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 1455
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------