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General NPI Number Information
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NPI Number | 1932473527
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Entity Type | Organization
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Legal Business Name | A PROSPERING VISION, LLC
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Dates
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Enumeration Date | 02/29/2012
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Last Update Date | 11/22/2016
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Provider Practice Location Address
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Address Line | 60 N MAIN ST 3RD FLR
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City | WATERBURY
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State | CT
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Zip | 06702-1443
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Country | US
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Telephone | 203-558-9865
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Fax |
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Provider Business Mailing Address
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Address Line | 60 N MAIN ST 3RD FLR
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City | WATERBURY
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State | CT
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Zip | 06702-1443
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Country | US
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Telephone | 203-558-9865
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE PROGRAM DIRECTOR
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Name | MR. ELIJAH CALDWELL
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Credential | LCSW
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Telephone | 203-558-9865
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 54084595001
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 5149
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License Number State | CT
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Taxonomy #3
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Taxonomy Code | 2084D0003X
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Taxonomy Name | Diagnostic Neuroimaging (Psychiatry & Neurology) Physician
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License Number | 040650
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License Number State | CT
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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