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NPI Code Detail

MEDICARE: COMMUNITY CHILD GUIDANCE CLINIC, INC.

MEDICARE: COMMUNITY CHILD GUIDANCE CLINIC, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261Q00000XClinic/Center0238CT
2261QM0855XAdolescent and Children Mental Health Clinic/CenterOPCC-14CT

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1780730267
Entity Type Code : Organization
Provider Name (Legal Business Name) : COMMUNITY CHILD GUIDANCE CLINIC, INC.
Provider Business Mailing Address
First Line : 317 N MAIN ST
Second Line :
City : MANCHESTER
State : CT
Zip : 06042-2007
Country : US
Telephone Number : 860-643-2101
Fax Number : 860-645-1470
Provider Business Practice Location Address
First Line : 317 N MAIN ST
Second Line :
City : MANCHESTER
State : CT
Zip : 06042-2007
Country : US
Telephone Number : 860-643-2101
Fax Number : 860-645-1470
Authorized Official
Title or Position : EXECUTIVE DIRECTOR
Name : MR. CLIFFORD JOHNSON
Credential : LCSW
Telephone Number : 860-643-2101
Provider Enumeration Date : 01/26/2007
Last Update Date : 05/03/2013

Similar Medicare Providers

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Practice Location Address:
317 N MAIN ST
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06042-2007
Practice Phone: 860-643-2101
Practice Fax: 860-645-1470
1609977685 — MRS. TANJA EVE LARSEN LCSW
Practice Location Address:
317 N MAIN ST
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1669540274 — LAUREN SCHEMPP LCSW
Practice Location Address:
317 N MAIN ST
MANCHESTER, CT
06042-2007
Practice Phone: 860-643-2101
Practice Fax: 860-645-1470
1972758308 — MRS. DORI Y BESSETTE-CRAIL MA, LMFT
Practice Location Address:
317 N MAIN ST
MANCHESTER, CT
06042-2007
Practice Phone: 860-643-2101
Practice Fax:
1952630519 — MR. CLIFFORD JOHNSON ACSW,LCSW
Practice Location Address:
317 N MAIN ST
MANCHESTER, CT
06042-2007
Practice Phone: 860-643-2101
Practice Fax: 860-645-1470
1508195025 — MS. DOREEN CASSIDY THIBADEAU LCSW
Practice Location Address:
317 N MAIN ST , L2
MANCHESTER, CT
06042-2007
Practice Phone: 860-643-2101
Practice Fax: 860-645-1470

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