=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285116707
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONNECTICUT COUNSELING CENTERS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2018
-----------------------------------------------------
Last Update Date | 08/31/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 290 PRATT ST STE 2312
-----------------------------------------------------
City | MERIDEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06450-8600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-317-2500
-----------------------------------------------------
Fax | 203-317-2525
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 BROOKSIDE RD
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06708-1402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-568-7466
-----------------------------------------------------
Fax | 203-568-7468
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR INFORMATION SYSTEMS
-----------------------------------------------------
Name | JASON BRADWAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-568-7466
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 0353
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------