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General NPI Number Information
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NPI Number | 1720539869
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Entity Type | Organization
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Legal Business Name | BOOST CHILD AND FAMILY SERVICES
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Dates
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Enumeration Date | 10/24/2016
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Last Update Date | 10/24/2016
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Provider Practice Location Address
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Address Line | 19 S COMPO RD
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City | WESTPORT
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State | CT
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Zip | 06880-4319
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Country | US
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Telephone | 203-557-8444
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Fax |
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Provider Business Mailing Address
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Address Line | 19 SOUTH COMPO ROAD
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City | WESTPORT
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State | CT
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Zip | 06880-1522
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Country | US
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Telephone | 203-557-8444
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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 | MRS. SUE BETH SIRLIN
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Credential | MA, LPC
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Telephone | 203-856-3372
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 000573
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License Number State | CT
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