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General NPI Number Information
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NPI Number | 1235737735
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Entity Type | Organization
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Legal Business Name | SOUTHBURY ADOLESCENT AND YOUNG ADULT COUNSELING CENTER
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Dates
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Enumeration Date | 10/15/2020
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Last Update Date | 08/03/2025
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Provider Practice Location Address
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Address Line | 519 HERITAGE RD STE 2A5
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City | SOUTHBURY
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State | CT
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Zip | 06488-6694
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Country | US
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Telephone | 203-568-5923
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Fax |
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Provider Business Mailing Address
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Address Line | 127 WATERTOWN RD
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City | MIDDLEBURY
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State | CT
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Zip | 06762-1502
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Country | US
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Telephone | 518-610-4528
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Fax |
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Authorized Official
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Title or Position | OWNER, LPC
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Name | MR. BRENDAN STACK
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Credential | LPC
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Telephone | 518-610-4528
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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