=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871344226
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROSPERITY HOUSE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2024
-----------------------------------------------------
Last Update Date | 04/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 190 WINTHROP AVE
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-908-8978
-----------------------------------------------------
Fax | 203-303-7243
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1435 CHAPEL ST 1ST FLOOR
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-908-8978
-----------------------------------------------------
Fax | 203-363-7243
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | KAREN MICHALE TYSON
-----------------------------------------------------
Credential | LADC
-----------------------------------------------------
Telephone | 203-908-8978
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------