Basic Information
| Provider Information | |||||||||
| NPI: | 1225334162 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVER VALLEY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 351 | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064577023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602625200 | ||||||||
| FaxNumber: | 8602625316 | ||||||||
| Practice Location | |||||||||
| Address1: | 455 SILVER STREET | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602625200 | ||||||||
| FaxNumber: | 8602625316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2011 | ||||||||
| LastUpdateDate: | 02/09/2011 | ||||||||
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| AuthorizedOfficialLastName: | FREDETTE | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | DONOHUE | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8602625244 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 007297 | CT | Y | Agencies | Community/Behavioral Health |
No ID Information.