=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164517801
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY SERVICES OF CENTRAL CT, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 58 MAIN ST
-----------------------------------------------------
City | TERRYVILLE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06786-5106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-589-6333
-----------------------------------------------------
Fax | 860-589-7934
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 92 VINE ST
-----------------------------------------------------
City | NEW BRITAIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06052-1433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-223-9291
-----------------------------------------------------
Fax | 860-223-3111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DR. MARK MURADIAN
-----------------------------------------------------
Credential | DPA
-----------------------------------------------------
Telephone | 860-826-1358
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | C-0285
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------