Basic Information
Provider Information | |||||||||
NPI: | 1265477780 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY CENTERS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 40 ARCH ST | ||||||||
Address2: |   | ||||||||
City: | GREENWICH | ||||||||
State: | CT | ||||||||
PostalCode: | 068306525 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2068694848 | ||||||||
FaxNumber: | 2068697764 | ||||||||
Practice Location | |||||||||
Address1: | 20 BRIDGE ST | ||||||||
Address2: |   | ||||||||
City: | GREENWICH | ||||||||
State: | CT | ||||||||
PostalCode: | 068305238 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2036292822 | ||||||||
FaxNumber: | 2096292940 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/18/2006 | ||||||||
LastUpdateDate: | 03/07/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORROW | ||||||||
AuthorizedOfficialFirstName: | TAMARA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | REVENUE CYCLE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2036292822 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X |   |   | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 004270039 | 05 | CT |   | MEDICAID | 004172920 | 05 | CT |   | MEDICAID | 004172912 | 05 | CT |   | MEDICAID |