=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568998706
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CATHOLIC CHARITIES OF FAIRFIELD COUNTY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2017
-----------------------------------------------------
Last Update Date | 05/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 EAST AVE
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06851-5703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-705-9711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 405 MAIN ST
-----------------------------------------------------
City | DANBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06810-4710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-743-4412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PATIENTS ACCOUNT MANAGER
-----------------------------------------------------
Name | MS. GLENDA MILLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-743-4412
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 104100000
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------