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General NPI Number Information
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NPI Number | 1477583581
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Entity Type | Organization
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Legal Business Name | BOYS & GIRLS VILLAGE
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Dates
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Enumeration Date | 07/04/2006
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 528 WHEELERS FARMS RD
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City | MILFORD
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State | CT
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Zip | 06461-1847
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Country | US
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Telephone | 203-877-0300
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Fax | 203-876-0076
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Provider Business Mailing Address
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Address Line | 528 WHEELERS FARMS RD
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City | MILFORD
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State | CT
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Zip | 06461-1847
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Country | US
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Telephone | 203-877-0300
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Fax | 203-876-0076
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Authorized Official
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Title or Position | CEO
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Name | MR. L. KENNETH FELLENBAUM
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Credential |
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Telephone | 203-877-0300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | EDT-10
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | OPCC-38
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License Number State | CT
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Taxonomy #3
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number | CCF/TS 17
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License Number State | CT
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Taxonomy #4
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | CPA-40
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License Number State | CT
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