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General NPI Number Information
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NPI Number | 1386701779
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Entity Type | Organization
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Legal Business Name | CHILD GUIDANCE CENTER OF SOUTHERN CONNECTICUT, INC.
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Dates
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Enumeration Date | 01/03/2007
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Last Update Date | 07/11/2019
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Provider Practice Location Address
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Address Line | 103 W BROAD ST
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City | STAMFORD
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State | CT
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Zip | 06902-3713
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Country | US
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Telephone | 203-324-6127
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Fax | 203-348-9378
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Provider Business Mailing Address
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Address Line | 103 W BROAD ST
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City | STAMFORD
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State | CT
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Zip | 06902-3713
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Country | US
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Telephone | 203-324-6127
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Fax | 203-348-9378
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Authorized Official
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Title or Position | ACTING CEO/CLINICAL DIRECTOR
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Name | DR. JESSICA L WELT
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Credential | PSYD
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Telephone | 203-324-6127
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | OPCC-4
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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