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General NPI Number Information
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NPI Number | 1154853307
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Entity Type | Organization
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Legal Business Name | BOYS AND GIRLS VILLAGE
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Dates
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Enumeration Date | 03/28/2017
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Last Update Date | 03/28/2017
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Provider Practice Location Address
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Address Line | 170 BENNETT ST
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City | BRIDGEPORT
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State | CT
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Zip | 06605-2901
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Country | US
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Telephone | 203-980-4625
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Fax |
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Provider Business Mailing Address
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Address Line | 170 BENNETT ST
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City | BRIDGEPORT
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State | CT
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Zip | 06605-2901
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | IICAPS CLINICIAN
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Name | KRISTA AMATO
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Credential |
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Telephone | 203-980-4625
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 10762370
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License Number State | CT
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