=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538622618
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARTER OAK FAMILY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2019
-----------------------------------------------------
Last Update Date | 08/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 843 MAIN ST STE 11
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06040-6041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-643-8870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 843 MAIN ST STE 11
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06040-6041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-643-8870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | STEPHEN R MACHATTIE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 860-643-8870
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------