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General NPI Number Information
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NPI Number | 1568835015
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Entity Type | Organization
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Legal Business Name | FAMILY SERVICES OF GREATER WATERBURY
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Dates
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Enumeration Date | 11/05/2015
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Last Update Date | 11/05/2015
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Provider Practice Location Address
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Address Line | 35 PARK PLACE
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City | WATERBURY
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State | CT
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Zip | 06702-1215
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Country | US
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Telephone | 203-756-4639
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Fax |
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Provider Business Mailing Address
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Address Line | 34 MURRAY ST
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City | WATERBURY
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State | CT
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Zip | 06710-1920
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Country | US
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Telephone | 203-756-8317
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | SANDRA PORTEUS
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Credential | LCSW
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Telephone | 203-756-8317
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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 | 0595
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License Number State | CT
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